04120077 CITY OFCUPERTINO
uu1LnlNC DIVISION PERMIT C¢¢ NTR`ACL,OR4NPORMATION x
.:I ,
nmf.DING ADDRESS: FERMA CORPORATION PERM]T Nc04120077
320 DE ANZA BLVD
ERS NAME: PERMIT ISSUE DATE
CTC, L. P. 1265 MONTECITO AVE 02/24/2005
ONE: SANITARY NO. CONTROL NO.
(650) 961-2742
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+O Zp
LICENSED
LCONTRACTOR S DECLARATION
d I herebyaffirm(KaiI am licensed underprevisions of9(commencing
Job Descriptiontion
w )) f Division Jof0c Businccvand Propositions Cole,and my license is
m fullform,and
effect. DEMO
Ji2 Z Do. Clue Contr
C$ ARCHITECTS DECLARATION
L a2 6 I understand my plans shall Xe used ss public¢ends
JyU
G Liaenxd Promsainnaf
vDs OWNER-BUILDER DECLARATION
<S5 1 hcrchy art,,.that 1 am excmpi from the,Contract., License Law fur IM1c
O o following mason.(Section 1031.5.Business and Pmfeuinm Code:Any city or county
5 m which requires a Permit to construct.alter,improve,demolish,or repair any atm<tum, $40000
Poor to its Issuance,also mquims the applicant for such permit to file a signed statement
that Kc is licensed pummon to the ponvishors of the Comorclor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation -
e�$ (commencing wi th Section 7000)of Division 3 of the 0 usines,and Professions Code)or
—
that he is exempt thcmfrom and be basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
not more than five hundred dollars(5500). e Occupancy Type
❑1,u owner of and ProacmYor is employees with wage ss Nei(Sec.comperostmn,
will pr Nc work.and the swaum ra not intended d or Law
do for sale(Sec.7044.Business
and progeny who cmc:The Cwtnnera acwho uw such
not apply to an owner is Required Inspections
own con who.s.provided
rolds or themer.impo and who does such work himself eof dRuougb his
own Employees,p building
or i that r such impswemenls em net internee m offered for sale. s-
how van Ne building or improvement is sold e within in one year of completion.provefor pu Owner-
builder will have dsc burden of proving that he did not Wild or improve for puryox of
sale.).
1,as owner of if Dforcing.am exclusively cornacling with licnued con vacmos o
consuoct the pmlen(Sec.1014,Business and Professions Cme:)The Convaaor's Li
c claw does not apply to an owner of property who builds or improves the men,an //',��
woo contracts for such pm' ntracmr(s)Iianx0 pursuanuo the Conuonor's C / '
License Law.
1 am cncmpt w ac B&P C for his mason
137Wat a Dale
R COMPENSATIONDECLARATION /
I hereby Affirm under penalty of pejury,one of the following declarations: Li 41111 U
have and will maintain a Certifcom of Consent to self-insum for Worker's Compen-
n,as provided for by Section 3100 of Be labor Cmc,for the performance of the
for which Of,Permit is issued.
have and will maintain Wurka's Compensation Insurance,as tcgared by Section
or Ne labor Cod..for the perrarmance of tW work for which Nis permit is issued.
Worker's Compensation Insurance carrier and Policy numher ale:
Carrier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mis section need not hecmnpleted U tha rctmit is fm onchundraddolla x($100)
of It
1 cenfy Nat in the coffin, pert M1p rk for which this permit is issued.I shaft not
any pecmna W
to � come subjc, o rlr�l'ork s���umMnsatimn
LawsCahforni� .cdryyfi
/A
Applicant
V/ NOTICE TO AQP Ehe L eking this Cisions or of Exemption.you should
Wcome subject y the Worker's Compensation previsions of the labor Code,you mon _
pforthwith comply with such pmvisi......his permit shall W deemed 2voted.
rCONSTRUCTION LENDING AGENCY
1 hereby affirm Nal there is a construction Icadi ng agency IOr the Performance or
3i
the weak to,which this permit is issued(Site 3097,Civ.C.)
y Q Landers Name
1 1<nder's Address
Z) z
J 1 certify Nat 1 have read this application and sure that the above information is
y F compo.I agree to comply with all city and county Ordinances and stale laws mining to
�(J building construction.and hereby authorim representatives of this city to enter upon the
4 above-mentioned property for inspection purposes.
y (We-)agree to an,indemnify and keep harmless the City of Cupertino against
') "
N liabilities,judgments,costs andc ,.I which may in any way aecme again said City
JZ in consequence of the granting of this Permit.
^ APPLICANT UNDERSTANDS AND-WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
vI Re-roofs
Sigmturc of Applicam/Contnclor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will dire applicant or future building Occupant store or handle hurardous material
defrnad by Ne Cupertino Municipal Cmc.Chapter 9.12.and the Health and Safety
..Seeeea zss3x')1 All roofs shall be ins ected rlor to an roofin material beim
❑Y.a Nn P P Y g g installed.
wits h appfcant or r lure building occupant sax agwpmcm or devices which If alroof is installed without first obtaining an inspection,I agree to remove
ern W,amnua ah limalins a Gefecd by the Bay Area Air Quality Management all new materials for inspection. -
Disumt?
❑Yes Nu
Ihave mad Ne dos a 'alsmquimments under Chapwr695orthc Cali for
nis HcalN&Safe aodc, r as
15,25533pnd Z5534,1undcmund Nmif Nc Wilmng
does not en ,mal n is mr.rcapnnain'nhy m nodry rte rccnPant nr N.
terbiumk to ' r.«,ssnanaeracen;feate4ro2panes. Signature of Applicant Date
eX Owner ma tbmirc`r-gcnt G Data All roof coverings to be Class"B" or better