05070109 CITY OF CUPERTINO /Y `��a �r" -�r� ry''��T{�� ryy•�a`y�� 'A�' �/�
BUILDING DIVISION PERMIT 'VSA+Oav+.�V•"��•L♦llill'.oA�'-"a7�'LgIJ�\��,, '
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BUILDING ADDRESS: PRUDHON BUILDERS PERMIT N0.05070109
OWNER'S NAME: PERMIT ISSUE DATE
7 PAGE JIMMY L AND JOLENE A— 1096 NORFOLK DR
SANITARY N0. CONTROL NO.
(408) 390-7251
ARCHTIECT/EyfCINEER: BUILDING PERMIT INFO
BO ELECT PLUMB MECH
Sop LICENSED CONTRACTORS DECLARATION JobDescrition
dr 0 1 hereby affirm that 1 am licensed under provision,of Chapter 9(commencing P
wrath Section 70110)of Division Sof Me Business and Pro essiom Code,and my license it
+� kmufmmmd.l!Wt. ,7 ?�/ 1121 ADDITION MASTERBEDRM AT FRONT
Llcrosc Class Lk.N
Deli — — GSDFC
OF HOUSE
G A CHTIECI•S DECLARATION
I unders and my plana MJI M used is public mcorda
SyU
r G t; Licensed Professional
OWNER-BUILDER DECLARATION
i I hereby affirm
that 1 am exempt from the Contractor's License Low for the
O 4 following mason.(Section 7131.5,Business and Pmfaafuns Code:Any city or county
3$ which re4uirea a permit to mnmucl,elmr,improve,demolish,or repair any suuctum
—iy prior to its issuance.also requires the applicant forsuch permit to file a signed statement
C that he is licensed pursuant to the provisions of the Contractor;License Law(Chapter 9 - Sq.Ft. Floor Area Valu (®g000
6B (commencing with SeNon 7000)of Division 3 of the Business and Prormiona Code)Or
that he u exempt rhemfmm and the thou for the alleged exemption.My vio1W'on of
Sma m 70513 by any applicant for a permit subjects Ne applicant to a civil Penalty of APN Number Occupancy Type
act mom than five hundred dollars(M). 36912013 . 00
❑L aaownerof Ilio pmpny,ser my ernploycn,with wages as Heir sale compensation.
will&the wok,and thesuucume is notintended Weirton]ferrets(Sm.7041,Business TI?d Inspections
Nfeta
d Prol9N Code:The ommactoes Limos Law dors not apply in N ReUIowner of q�'rbd 41 P
property who builds or improver thereon.and who does such wok Mmsetf or through his
Own employees,provided that such improvements are notimer ded oraRered for sales if.
however.the building a improvement la mid within one)ear of completion,the owner. J
Wilder will have the burden of proving that he did not build m Improve for purpose of <•gJ'T?
If
❑
l 1,as Owner of the propertyrt aexclusively contracting with licensed contractors k s� V,s�p?�
constmm the project(Sec.7014,Business;and Professions Code:)The Conuacmlt U-
ce --Jjf/� n
ase lato w 4.not apply an owner of property who builds or Improve Mercer.rod,
who contracts for such projects with a conusceor(s)liaoxd penman,to Ne Conuactofs (�Q (/
Liana Law. qr y
❑lomrxemptunder Sec. LAR Data,BAPCfData Vm Nlsmanon q
Owner 'H�9!'JtJ"tI p�
WORKERS COMPENSATION DEC
I hereby&Rom under penalty of perjury arc Offt following declarafloor
ve and will maintain ACeNOcauarCmuem to¢Ifdnsum forWakeYaCompn-
1an,as provided fm by Section 5700 of the Labor Code,for Ne parfarmana of Ute
wok for which this permit Is issued.
❑I haw and will maintain Worker's Compentiedon Insurance.As required by Section
3700 of the Labor Code.for the performance of Ue wok for which this permit is issued.
My WokeYs Compemedonl Unna Eartier stud Policy number ere:
Carnes. Policy No.: •--��—
'CERTIF7 •OF UMPTION FROM WORK EPS
COMPENSATION INSURANCE
CMisctmrecdnothecmpktrdifthemmi,isformehmN ]noon(5100)
m kav)
1 certify that in the peeformeace of Ne work fm which this Permit Is Issued,i rhall not
employ any person in any manner an As in becamesubjec,to the Workcss'CompntsNOn
Iawr of California,qtr
Applicant
NOTICE TO APPLICANT If,after msldng this Certificate of Exemption,you should
become subject to Ne Wak=fa CompMatien p visiam of the Ichor Code•you muse
.J O foMwiN comply with such Provisions,or this permit seta11 k decreed rooked.
zy CONSTRUCTION LENDING AGENCY
t" I hereby afOrm that Nero is a commuctlan lending agency for the perfmmama of
6i the wok for which Nu pemtit Is usned(Ser.309E Civ.C.)
aQ IaMels Name
P z Iamice.Address
U O 1 certify that 1 haw mad this application and wit W,Ne show information u
U.r'. torten.l agree in comply with all city and county ordinances and state Ito neluing u
p Vr building construction.eM hereby mthodme repmeneaim of Nu city to enur upon the
W above-mentioned property for impcnlon purpmes.
a (We)agme tomes,indemnify and kap hamicas Ue City of Cupertino against
y
liabilities Judgments.cmu and expenses which may in any,way acme agaimt acid City
U 7 In consequence of Ne granting of Nis permit.
�7 APPLICA NDERSfAN AND ILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE DL177GN5.
3-05 Re-roofs
of PP n HAZARDOUS MATERIALS DISCLOSURE Deck Type of Roof
Will Ne appliunl m fulum building accupantsmm arhcandle hanNous material .
As defined by the Cupertino Municipal Code.Chaper 9.17.and Ihe'Health and Safety
COln.SeNon 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yu RNe
Will the applicant i acesfutua Wilding by ft B,use equipment Qu or devices which
If a roof is installed without firs[obtaining an inspection,I agree to remove
hazardous air cmtsmirunu u dc0ned by Ne Bay AmaAir Quality Managcmcnl all new materials for inspection.
7
❑sen u
I ham mad the hon s requirements under Chapurd.95ofMae Califm-
nuHeal"SafmyCode,SaUom25505.25533 W25534.1 undemad thairte building
daa rot c dy have tem
en.ten.Nat u 11 my responsibility notify the occupant of the
require whichissuance or.Ccrvfauofo ^D Signature of 9rinApplicant Date
nor or AM m ton 'mm uthorindagent Dae All roof coverings to be Class"B"or better
L