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CITY OF CUPERTINO
UT NF
BUILDING DIVISION PERMIT
BUIL DING ADDRESS:
455 BYRNE AVE,
FERMA CORPORATION
PERMITNO.05080201
R'S NAME:
PERMITLSSUEDATE
SESHARAO PATCHIPALA
1265
INE:
SANITARY NO. CONTROL NO.
(650)961-2742
ARCHITECUENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
P
apmr 9 (commencing
I hereby affirm Nal I am licensed under provisions of Clinger
3 dm Business Prof9ssioe Code. and my licerme is
with Section ](Id(1) of Division of and
in full to= and
DEMO (E) HOUSE `a `a?% (1,r
Umenm Cl.ss Lica
Dale ConlnCbr^�
ARCHITECTS DECLARATION
'• •j
(✓ti'e' ��
1 understand my plans shall M rued es public rtcnrds
/ a 9 yt. � '�
r •'^®
^3 a/
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 em exempt from the Contractor's Licence Law for Ne
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pppp fIt '/�
following motion. (Sudan 703L5, BOsinexamil Professlom Code: Any city or countyr-
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cR
which requires a permit to con3lmCL alter, improve. demolish. or repair my SWm
to �'�' j'„t! 88000 O O O
O
prior m its issumer. also requites the applicant for such Permit rile a signed statement
Contractor's Limens Law(Ch.p¢r 9
Sq. FL Floor Area
V fl:Ii"t Valuation
Inas he is lmpursuant ensed pursuano the Previsimrs of the
(commencing with Section ]OW) of Division 3 of the Business and Professions Code) or
QYjA/,y.
that he is exempt Ocmfrom and the basis for Ne alleged exemption. Any violation of
g
Occupancy Type
Section ] W 1.5 by any applicmn for a permiuubjects Ne applicanuo a civil Penalty of
not marc dun five hundred dollar, ($500).
❑ 1, u owner of Ne pmpcmy, a my cmplayces with wages u IKir Sale compensation,
Required Inspections
will do Ne work end Ne swnure u not imm�dcd or attcrtA fonak (Sec. ]Odd, BusiM..
and Professions Cade: The Conummrs License Law does out apply in an Owner or
properly who builds or improve thereon, and who doe, such work himself or Omugh his
own employees. provided that such imprommcnts arc not intended or Offered for sale. IL
however. the building or impoo mens is said within one year (ifcompletion,the owner,
builder will have the burden of proving that he did nut Wild or improve for purpose of
salc�).
g 1, as owner of the promor, , am exclusively convecting with licensed conoaeem, to
consumer the project (Sec. ](134, Business and Professions Cade:) The Convenor's Li-
ceve law does not apply in an owner of property who Wild, or improve demon. and
who contracts for such pmjccu with a contrstor(s) licensed pursuant to the Comrano's
License Law.
❑ I am exemptunder Sec.( B&Pero thisrecon
GIL��rl�DO iDT(.WdB-LX Dale
WORKERS CO ENSATI DECLARATION
1 bemby affirm under penalty of perjury arc of the following decimations:
1 ham and will maintain a CcW ficam of Conxm to self -insure for Wortets Caused-
smion. as pmvided for by Section 3700 of de labor Code, rat the performance of the
'
work for which this permit is issued.
_1 1 have and will maintain Worker's Compensation Insurance. as required by Section
37W of the labor Code, for the performance of the work for which this Permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier. Policy No.: _
r CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(Thu section need not tecompleted if ibe Permit is foronehundred dollars(5100)
or less.)
1 cenifv that in the performance of the work for which this permit is issued. I shell not
LTPay ant' person in any manaCf 311 az n11MCamC Sm 1jCCl m 1nC Work[r5 ComPCniatlon
Laws of California, Da
Applicam
NOTICE TO APPLICANT: If, after Asking thiltruricalic of Excumptiori load should
become subject in Ne Workers Competsauon previsions of the Leber Cade, you mug
' foMwith Comply with such pmvisiom or this permit shall be d¢mcd revoked.
CONSTRUCTION LENDING AGENCY
1 hereby rd- Nei there i, culla [ending agency for the performance of
w ich s ed (Se
' the work for which this permit is issued (Sec. 7(N]. Civ. C.)
'
Lender's Name
,
Lender's Address
j I certify that 1 bam read this application and state that the above information is
' torten. l agree to comply wish At city and county oNinauces and sum laws missing to
Wilding conswction, and hereby aushonx representatives of this City to enter upon the
ahovcmcnuoned property rot inspection puBeses.
(Wc) agree to save, indemnify and keep harmless the City of Cupertino against
j Liabilities. judgments, costs and expenses which may in any way ammc against said City
in consequence of the grand ng of this permit.
' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS. nn
Re -roofs
_
Type of Roof
Axl. a c n Wiul,.l.(st JA f o�Ie'_
Signamrc of ApplicanUCon r ale
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building amusing store or handle havardous mamrial
as defined by the Cup in. Municipal Code. Chapter 9.13, and the Health and Safety
e. sermon zss7zan
All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑Nam
If a roof is installed without first obtaining an inspection, I agree to remove
Will shc applicant or future building occupant use equipment or devices which
mil hevardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes ON. /3
1have renal them,WOrdmis under Chapter
Secummaterialsrequirements
mad ifthe Wilding
5533 25534.1 understandmadm cup Wilding
Sccdoehat
Hnot
do
doe not curtemly have a tenant that it is my rcsponsihilily to notily dm acuPenl of Ne
CurSntlyhave a iii my
Icquircmcnts which mug W priormismancea(a Cenlficamo(Occup my.
/LS
Signature of Applicant Date
I 3
All roof coverings to be Class "B" or better
m
Ownr autharivcdstem
er om