04110084 ' CITY OF CUPERTINO-
BUILDING DIVISION PERMIT f (7k11Vlt��Tl a;
_ „ ? ,��.,z�, yrs .t« ,�� ',• _. . _
" BuILDIncADORFss: LLOYD K NORHEIM ,GENERAL , aERMITN04110084 —
ER'S NAME: .. ,. ... FERMITMUEDATE
ONE:'. •".- - SANITARY - 2 4C ARCIL NO. --
ARCHITECT/ENGINEER: _ BUILDING PERMRINFO
BLDG ELECr PLUMBS MECH
0 o t — = _
no,o -' LICENSED CONTRACTOR'S DECLARATION -
I hereby from
ffirm that I am licensed unda, provisions of Chapter 9(commencing Job De$CrlptlOn.
with Section 70(kDivision 3 of the Basin.,and prnfessiutis Cadd license is
my liceis
_ w in full fosse and effect,
Lima.Cass Lte:g .REVISION--INHOUSE USE ONLY
Dale _ CanlnCtnr
NO NEW PERMIT ISSUED/ .ORIG. #03120100
ARCHITECTS DECLARATION
I undcrstanJ my phna shall he mud u public recnNs �� '` �- � � -� "- - - .,
3 G .Licensed Professional
S OWNER-BUILDER DECLARATION
I hemby affirm that am exempt from the Commerce.License Lew for the
-- M O fallowing mason.(SCNon 7031 5,Business and Professions Code Any city or county .. •,�� - µ
$ which requires a permit to construct alter.Imp row.demolish,or repair any structure
Fiy priorw its iuuanm.also regmreslhe applicant formch permdro rile asigned attention* ^C thathe is lucns.d pancreatic,the provisions of the Contractor's Ulcera law(Chapmr9 ,- Sq.Ft.FIOOC Area VBIUafIOn
m�a (commencmgwidi Smtion7(100)uf Div'uion3oftbe Bustrteasand Professions Coim)m
^ that he ix exempt thomfrom and the basis far the alleged eumpdun.Any violation of .
Scott=7031.5 by any applicant for a permit objects me applicant to a civil penalty of APN Number - . Occupancy Type
not more man five hundred doll..($5011).
❑I.0nwnerofthepmpcny,ormyemployenwithwageutheinolccompen.don,. .
will do the work and the stmctarc is runmerided oroffered fouale(Sm.7046,Business 18 00 ,
and Professions Cc&:The Conumanr's License Law dors not apply to an owner of Required Inspections
prupeny who builds or im prove mereon and who does such work himself or mmugh his
own emplayeuilding or improvement m meh ire is sold nuau n year fcomplfeled forto ow.r-
however,the building he within year or Improve n.
me owner- . ... _. ., _
bailder will have me burden of proving that he did not build or improve(or pegroae of - -
aakJ.
I.as owner of the property,am exclusively contracting with licensed comancrcn to -
. . ronxwct the project(Sec.7(A1,Business and Professions Code:)The Contractor's Li-
cense law dors not apply to an owner of properly who builds or improves thereon,and,who contracts for such projects;with aconwcmr(.)licensed pursuentbdon Contractor's "^--'^---'---- "'------
License I.
❑1 am exam undcpfeecc. ,B&P Willa
Dem
WORKER'SCOMPENSATIONDECLAR TIAT '
1 hereby affirm under Penalty of perjury arc of the folia lumina:
I have and will maintain a Certifie,of Consent to self-meale for Workers Compcn-
.don,.Provided for by Section 3700 of the Labor Cade,for the perfmmetue of the
work for which this Permit is issued. .
I have and will common Workers Compensation Insurance,as required by Section - " -
3700ofthe LsWrCocke.for the performance of the work for which this permit is issued. -
My Worker's Compensation Insumnee carrier and Policy number am:
Carrier: - Policy No.: ._ .... .
"CERTIFICATE OF EXEMMON FROM WORKERS' _ -
' COMPE14SAIION INSURANCE' " -
(rds section need noth.completed iflhe Permit is fortune hundred dollars( I00) -
orteaa)
1 certify that in the performance of me work for which this permit is issued,I shall not
employ any Person in my manner so u in become subject to the WorkariCompensation - -- _
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:If,after making this Certificate or Exemption,you should --
income subject to the Worker's Compensation provisions of the Labor Cram,you must
.J z forthwith comply with such provisions or this Permit shall bc deemed revoked.
„zt 0 CONSTRUCTION LENDING AGENCY
is I hurmyaffirm mat mart in.construction lomingagen,forth.performance of - -
g:r the work for which this Permit u issued(Sec.3097,Civ.C.) - -
Q Lender's Name
z Lender's Address
V O I certify that 1 have lead this application and state that me above information is
ly P correct.l agree to comply with all city and county ordinances and state laws relating to
0U building construction.and hereby aumorim ammaemativcs of this city to enter upon the
�w about-mentioned property fm inspection purposes.
Ow (We)agree I-saw.indemnify and keep harmless dte City of Cupertino against �'/ �•'
to liabilities,judgments,costs and expense which may in my way accrue against mid City [/ /
(„)Z in consequence of the granting of this permit,
^ APPLICANT U DERSTANDS AND WILL COMPLY WITH L NON-POINT Issued by: Date
SOUKCE REG YN.ofATIO
�� l5 d Re-roofs
S rule ofA IicmV om rsom, D te
HAZARDOUS MATERIALS DISCLOSURE Type of Roof '
Will the applicant or future building occupant store or handle hmmmmus material
as defined by the Cupertino Municipal Cade.Chapter 9.12.and the Health and Safety
Schon 25532(.)7
Ely. AAll roofs shall be inspected prior to any roofing material being installed.
Win the applicant ar mtar riding occupant use equipment or device.which If a roof is installed without first obtaining an inspection,I agree to remove
arch hamolmis air cannminan as defined by the Bay Area Air Quality Management all new materials for inspection.
Dismicty
❑Ycs 77 No
1 have read the humdmus materials requilerncnu under Chapter 6.95 of me Califor.
nia Hceltb&Safety Code,Smmwx 25X15,25533 and 25534.1 understand here if me Wilding
dors not curtc y haw amount,mat it u my leapansibility to notify occas rot of m,
requite ichm t matPriormissuanceoracomficateof uPon 'SignatureofApplicant Date
zw?er ser ari'r, ascan i All roof coverings to be Class aBa or better