04120078 CITY OF CUPE RTINO
BUILDINGDIVISIONPIRMIT CONTRACTORINF,rQRMATION',
c ,
BUILDING ADDRESS: FERMA CORPORATION PERMIT NG04120078
10370 DE ANZA BLVD
ER'S NAME: PERMIT ISSUE DATE
L CTC, L. P. 1265 MONTECITO AVE 02Z24/2005
ONE: SANITARY NO. CONTROL NO.
(650) 961-2742
ARCHITECT/ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0
io0 LICENSED CONTRACTOR'S DECLARATION
G with 1 Mrcby gram that 1 am Barecd under previsions of Chapter 9(commencing Job Description
U Section 7001)orDivision J ofthe Business and Professions Code.and my license is
In full force and effect. DEMO
in License Class Lic.0
SFO Date Contractor
ARCHITECTS DECLARATION
f re< I understand my plans shall be used az public records
)yU
O Licensed Professional
S OWNER-BUILDER DECLARATION
in
y 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Profesxluns Code:Any coy or county
<m which requires a permit to cwxtroa,alter,improve,demoliaA m repair any structure (I O Q Q Q
v¢i prior it)its issuance,also requires the applicant for such Permit pie a signed statement
a that he is licensed pursuant to the previsions of the Contractor's Lictme Law(Chapter 9 y by a.Ft. Floor Area Valuation
e�0 (core merlin,wim Section 70DO)n(Dlvoida 3oflbe Business and Professions Code)or \ 'I!
that he is exempt therefrom and Ne basis for the alleged exemption.Any violatlnn of /��_ l / "ST.
Section 7031.5 by any applicant for a permit subpett He applicant to a civil penalty of Occupancy Type
not mom than five hundred dollars(55007.
O I.as owner drum property.or my employees with wages as their volt compensation,
will do the work,and the structure is not intended or ofread rorsale(Sec.7 W.Business aa/ 1�� M,
and Professions Code:The Conmcmr's License Law does not apply to an owner of V / Requirednsgections
property whobuilds orimprows themon,and who does such work himselfor through his
bon employcu,provided that such improvements are not intended or offered for said.If.
however.the building or improvement is sold within one year of completion,the owner- U lj 1
builder will haw me burden of proving that he did not wild or improve for purpose or
sale,). ° /
xs1.a owner of me property,,B sine exclusively competing with licensed Contractors i
cemad a me es project(Sec. a in Business and Professions ds or imps Contractor's nd
h (ave does not aPP1Y to m owner or ducturproperty who wilds or improves thcrean,and
W OCon=ch foil" pro' wiNacomm�pr(s)liarvetl pursuam mthe Conmaoh J
Licame Law. I
❑lam aacmptP .B&PCf this awa /',
net
Ua
COMPENSATION DECLARATION
1 hereby iffim under penally of perjury,one of the following declarations:
I his ve and will maintain a Cerificae of Consent to self-made for Worio scompere
sation,u provided for by Senior 37M of the labor Code,for the performancc of the
work for which Nis p,nnit is issued. .
❑1 have and will maintain Worker's Com,dom or Insurance,u required by Section
]700 of the Vbor Codc.for the performance of the work for which this permit is issued.
My Warkcrx Compensation Insurance Carrier and Polity number art:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORK F.RS'
COMPENSATION INSURANCE
(This smith need not tecompleted if the Irrmit is for one hundred dollus(5100)
or less)
1 certify Na in the arrinam r the work for which Nis permit is headed.l mail not
m to any ren in abecoon . Ccuot W c sation
e P Y )per an I G/��
Laws of California x•— P
Applicant i1
NOTICET P ing this Ccnificam of Eacmpion,you should
become subject to or "mpcnsatim previsions or the tabor Codc,you m d
�7 forthwith comply with such provisions or this permit shallw deemed revoked.
Z OCONSTRUCTION LENDING AGENCY
I hereby affirm that more is a Construction lending agency for the Performance or
x Ne work for which Nis permit is issued(See.3(N7.Ci,C.)
21 tenders Name
z Lender's Add.,
J p 1 comfy that I have read this application and stat,du the above mums uiun is
y F Corbett.I agree m comply with all city and count,ordinanas and state laws relating to
�U wilding construction,and hereby aumesm
orim reprcativeS of his city to enter upon the
w above mentioned property for inspection p rands
(We)agree to save,indemnify and keep harmless the City of Cupertino against
h I iabi lidos.judgmen¢,costs and expenses which may in any way accrue against said City
;)Z in consequence Of the granting of this Fermi 1.
�-^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
e-roofs
Signature of ApplieanVConlraelor Dale
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or future building occupant store or handle hararduus material
az dc0netl by dm Cupcnino Municipal Code,Chapter 9.12,and the Health and Safety
we.semen zss3z(a)y
❑Yes [4- All roofs shall be inspected prior to any roofing material being installed.
Will mea licam or fuium building t equipment or device:which If a roof is installed without first obtaining an inspection,I agree to remove
PP s bycapon pee
7Di,Inc,1
havallous air mmaminants u dchncd by Nc Bay Arca Air Quality Management all new materials for inspection.
❑Yes f�1 Nu
Ihow read me ws ®materacalm&Safer `�'umi]y)5,25533 and 25534.1 understand that if me Wildin nest curve tl yh e 4ttanI,t�rrr it is my respo jhiliiy tO ntify the..,.iof he
irem wlp n riu rissu aCcrtihcamofSignature of Applicant Date
,CdDatAll roof coverings to be Class"B" or better
r.w d�rea Dam