04120074 CI'FY OF CUPERTINO � uT• ,a"� ` 2ti '`��• �""' '
BUILDING DIVISION PERMIT C®NTRACTOR INFQRMATIONc,
�;,4 v
Bu1LDING ADDRESS: FERMA CORPORATION PERMIT NG3412 O 074
10350 DE ANZA BLVD
NF,R'S NAME: PERMIT ISSUE DATE
CTC, L. P. 1265 MONTECITO AVE 02/24/2005
NE: SANITARY NO. CONTROL NO.
(650) 961-2742
ARCHITEC IENCINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
+op LICENSED CONTRACT'OR'S DECLARATION
w I hereby affirm that I am becomd under provision or Chapter 9(commencing Job Description
FZco with Section Bail))of Division 3 ofthe Business and Professinm Code,and my license is
<< infall fn¢eandcffecl, DEMO
i = License Class Lim.a
,rn Dam Came.,.,
MARCHITECTS DECLARATION
1 understand my plans shall be used as public records -
5dU
r GLbaau
cd Professional
`9mg OWNER-BUILDER DECLARATION
A a f I hereby affirm that I am exempt from the Contractor's Licemu Law for the
00 following reason.(Section 7031.5,Business and Profession Code:Any city or cnumy
e m which requites a permit to construct,alter,improve,demnlixh,or repair any mncmm $40000
four it)its issuance.also me,min the applicant(orsuch permit to Glc a signed statement
'so lharheislicemedpursuanttoNcpmvisionsofNcCarl.,.,,LicenseLaw(Chirac,9 Sq. Ft. Floor Area Valuation -
rt- (comm racing withSectiun 7000)of Division 3 of the Business and Professions Code)ter
$
that he is exempt therefrom and Nth
e basis far e alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty Of e Occupancy Type
not more than five hundred dollars(5500).
❑I.sa owner of the progeny,Or my employers with wages as their sale eompetsel
will do Ne work,and Ne mm cture is not intended or offend fors (lace.70aa,Business
and Professions Code:The Contractor's License Law das not apply to an owner or �eT 'I) Required Inspections
property who builds or improves thereon,and who das such work himself or through his
own employees,provided that such improvements are not intended m aRered fm sale.IL y
however.the building or improvement is sold within as year of completion.the mine(- r
builder will have the burden of proving that k did mol Wild or improve far purpose of y - ��-'••
Salm)
❑1,as owner of the progeny,am exclusively condoning with licensed contractors 1.
construct the proket(Sec.7044.Business and Professions Code:)The Contractor's Li-
tour Law dao not appl o r progeny who Wilds or improves mention.and
who contracts for su canmctor(s)licensed pu.suanuo ftConuacnr's
License,Law.
�Iam ear ro'p ,B�mr&PP11Cf this,
ner un / ER'S COMPENSATION DLCLAR T10 e.
1 hereby affirm under Finally of perjury one of the following declarations:
1 have and will maintain a Cenifaca¢of Continuo u1f-insure for Workers Compete
.—u provided for by Section 3700 of she Labor Code,for the performance of the .
work for which Nis permit is issued.
❑1 have and will maintain Worker's Compenenion Insurance,u required by Section
37W of me Labor Code,for the performance of the work for which this permit is ismed.
My Worker's Compensation Insurance carrier and Policy numkr an:
Gmcr: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisuclio i need not k cmmplemd if thera mth is formic hundmd dollars(SIIgB
or Ices.)
I rem"N4400n�_
, work for which This Pcrmy is issu d.I shall mol
employ anmkc esubjat h of slrpensation
Laws of
AppOcam
NOTICE after making this Ccrarcale of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you maw
z roMwith comply with such provisions or this permit shall the deemed rewkcd.
Z O CONS RUCTION LENDING AGENCY
I hereby affirm that there is a eamtr nChim lending agency for performance of
Y Ne work fur which this pcsmi5 is issued(Sec.3097,Ci¢C.)
+ T7 Q Lenders Name
Lender's Address
J Q 1 ccnify Net 1 have read this application and sum that the above Information is
y rorccL.1 agree to comply with all city and county ordinances and sum laws relating to
DU building eonswction,and hereby authorim apeaccomims or this city to enter upon Ne
Y W above-mentioned property(or inspection purposes.
CW (We)agree to save,indemnify and keep harmless Ne City or Cupenin0"gains,
habilities,judgmenu.costs and expenses which may in any way"cane against im at City
;J Z in consequence of the rimming of this permit.
'-' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
Signature ter ApplicaDam
HAZARDODO US MATERIALS DISCLOSURE Type of Roof
Will the applicant or furore building Occupant Store or handle h ad
az defined by Nc Cupertino Municipal Codes.Chapter 9.11,and be,Health
caIN and Safny
cadre.seaon 25532(a)?ous �"
All roofs shall be inspected prior to any roofing material being installed.
❑V
Will due applicant or fuwrc building Occupant use equipment orUcvices which If a roof is installed without first obtaining an inspection,I agree to remove
41 mi,hareednus air conuMnanu az&ri cd by dm Bay Arca Air Quality Management all new maters AT-s for In ection.
Dismia7 yyy
❑Yes Iy No -
Ihave mad!gKolf Wi5m
yuimmcnts under Cha Sharif veCalifon
is Heal N&S 33 am125s3a.lundcapair Nm if Nc Wilding G
don not cu 1y niihilitY am nmtilYt SccuP t c
myaire ts amracmrdfcamor apau Signature ofApplicant Dale
Ovr ,cd oBi Date All roof coverings to be Class "B"or better