04030245 CITY OF CUPERTINO Q art, •:
BUILDING DI VISION PERMIT s��,' �1. (7 � RMATIO
Na i
BUILDINGADDREss: LLOYD K NORHEIM GENERAL PERMIT ND.04030245
OWNER'S NAME; PERMITISeaURDATE
GARY B
ONE: SANITARY 0 OL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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�Cpp LICENSED CONTRACTOR'S DECLARATION Job Description - - - '
1 hereby affirm that 1 am licensed under provision of Chapter 9(commencing p
whi Seedon]000)ofDb,ba W 3 of Nc Becinessand Professium Code,and my license is
in fan force and.ffc. TEMP POWER POLE r N F�IlIA►LEGD
5 jq,? Lleentt Clue Lk.N
Z—MDate CARCHITETDELARATION APR V O 2004
sY hall
M wad As public records
3 t O Licenced Professional
e'O OWNER-BUILDER DECLARATION BUILDING
+� I hereby.(firm on 1 I.S.Bumpe from the Contrns Co License Lew for the my
Ea o which mg moon.(Section]031. Business and Professions Cad,:Any city of county
$ which roquircs a permit w uiwAt eL a@r,improv,dcermitt area sig any slmmure
Fiy prior At dui issuance,alw roquim the applicant for such permi,tofilea signed statement
< mmhcincing cd parsuam mDO)NDislo,uoofflo,nulaosssuansculons Code)or Sq.Ft. Floor Area Valuation
z�r
�'3$ (commencing Seaport 7000)oA loodsofrnf,hcBminuemton.Any
lMr he le exempt New(rom and Ute buss for the alleged exemption.Any violation of
Semon 7031.5 by any appib eat for s permit aubjecu the Applicant 10 a civil penalty of 3-MN ft1*gr0 0 Occupancy Type
not mora Nan Ow hundred della.($500).
❑[.uownerofthepmpersy.mmyemploymwiLh agun Nelrmkeampenulion,
willdothewaric. ndthestrumusei...Iintendedmoneredran].(Sec.7044,Business Required Inspections
end Professions Code:The Contractor's License law it= em not apply w an owner of q P
properly w ho builds or improves Hereon,and who does such work himself or Through his
own employees.pootdcd that such improwmenas are not handed ransred fertile.IL
howaveq the building or improvement is sold within ane yeti of Compi.d..,the aawm-
builder will have the burden of proving that he did not build or improve for purpose of
tile.),
n owner of One property,am exclusively Confounded,with licensed contractors to
I the project(Sec.7614.Business and Profusions Code:)The Contractor's Li.
costs law dm not apply to an owner of property who builds or improves demon.and
who contracts for such projects wilt,a Contnauldl)licensed pursuant On the CMM ect.e.
Liccnm Lew.
❑'Amex. ,under Sl ,B&PC rNis on
Owner ' Dew"I". -
WOR 'S COMPENSATION DECLARA
1 Newby ffnm under penalty of perjury one of the I.It .
1 have and will maintain a CertlOcew of Consent in ttl6iuum for WorkerSCompen-
Milan,As provided for by Section 3700 of don Labor Cade,for the performance of the
work for which this Permit is issued.
❑I have and will maintain Worker's Compensation Insurance,As required by Section
3700 of N.labor Code.for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance ender and Policy number are:
Cartier. policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not becomplewd ifrhe Permit is frronc hundred dollars(SIM) -
m less)
1 codify Na,in Ne Performance of the work for which this permit is issued.I shall not
employ any person in my manner so At w become subject to the WorkCrs'Carpenamen
Law,of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Cenifmcala of Exemption,you should
become subject in the Worker's Compensation provisions of tie Labor Code,you must
Z foMwith Comply with such provisions or this permit Mall be deemed ranked.
z CONSTRUCTION LENDING AGENCY
[ti I hereby affirm Nat them is a construction lending agency for the parfurmance of
!Yi> the work for which Nis Permit is issued(Sec.3097,Civ.C.)
aQ Lendcls Namc
z Lead es Address
fJ O 1 certify that 1 have red this application and suite that the above information is
{L F correct.I agree in comply with all city and county ordinances and site saws relating to
V building construction,and hereby auttnui
owi.mpretiwa of Nis city to cater ulna Ne
>0 fJ above-mentioned property for impaction purpous.
C (We)agree to save,indemnify and keep hermkas the City of Cupertino against
tort liabilities,judgments,costs and expenses which may in any way me=against said City s
fJ 7 in consequence of the granting of this permit.
r7 APPLICA UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
SOURCE ULAT S
3o Re-roofs
Si of AppluxamuCtoIdirt. I D
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or future building occupanrstow or handle haallous mawnal
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cade.SO no.25532(07 All roofs shall be inspected prior to any roofing material being installed.
Yes a 9u
Will,he applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit Woodnu air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Dinner'!
❑Yu
I have real the bacandom,mAwd.lx re pthomemaunderChaptar6.95 of lie Califor-
nia Fka1N&Safmy Code,Secdons75505,15513 and 25534.1 underslantl tha,i(Ihe building
dm nm ally haw a tenant that i,u my rosponsin iry to noel' the pan,of the
wgaiw hicham nor toismance.f.Cerdreaw w y Signature of Applicant Date
owns ,ba a.dasent All roof coverings to be Class"B"or better
71
Community Development
aClOF
10300 Torte Avenue
Cupertino CA 95014
Telephone(408) 777-3228
Fax(408) 777-3333
�UPEI�TINO
Building Department
JOB ADDRESS: 1 Og l O jMtmUAAXr L. E PERMIT #
CAPetria 0 .6
- C -VI o2�lS
OWNER'S NAME: 01UA4 PHONE 6314,15,oZ
GENERAL CONTRACTOR: D OR4I�LNti FAX # D8 (v 9
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation K
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
30 0
Owner/Contractor Signature , Eke
CITY OF CUPERTINO
SASTEMP POWER o'�
UPEkTiNO PERMIT APPLICATION FORM
IMF APN# 37T
l (,/ �� f� Date: 30 O
Building Address: J
t0310 1S)3 4*a-r LAAc o sn I
Owner's Name: Phone#:
&A-k(4 160$
Contractor: Phone: License #:
Contact: Phone: Cupertino Business License #:
r>tA-GK s-�t P.P tia b 3q- 93 02-
Building
ZBuilding Permit Info:
Elect
Job Description:
Residential Commercial ❑
Cost of Project: oc
Qt . if
A li b Fee ID Fee Description Fee Group
TEMP Temporary Power ELECTRICAL
PERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
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