04100020 CITY OF CUPERTINO
BUILDING DIVISION PERMIT .CO NTRACTORIlVFORMATION
f,Y '31
BUILDINGADDRESS: FERMA CORPORATION PERMIT"'04100020
10411 (41-ENCOE, DR
OWNER'S NAME: PERMIT ISSUE DATE
S & H INVESTMENTS 1269 MC)NTF.('.TTn AiTT7.
E: SANITARY NO. CONTROL NO.
(650) 961-2742
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
ION
LOp LICENSED CONTRushoom nd Pree ons Coa ��■ V/ d�a�®
x U C I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing cr
'Il■pt�"
� w with Sation]OBU)of Division3aflW Busircuand Professiuru Codc.md myliccmeit
in full fame and affect. DEMO (E) HOUSE
j License Cuss Lic.Is
r Dme Cora-
ma-ARCHITECTS DECLARATION OCT / 2004
�y rags< 1 undcrsuW u nJ my plans shall used Public rocnNs
Oyu
;4� Licensed Professional
"m OWNER-BUILDER DECLARATION
0 I hereby affirm Net 1 1. exempt from the Gamester's LJecnse Law for the BUILDING
p O following rias,..(mans t 7031.5.Business,.mr. and ove,de um Calc:Any city nr county
se S ta which requires a permit so consnues alter,imPmw,h KMit t m repair any aw.tu t
Fiy priormiu tensed ,akant to ma pamsewieam far Cmdrartniuoicense ma(Clotemem Valuation
< dutMincingwJpSectio 7use")of
viviomnfNCConuiness niccnmlaw(Chapscin Sq. Ft. Floor Area
(commencing with Section]0ndth Division3 MlWBoul exemption.
pion.Arymm Code)in
a. $ that he u exempt therefrom and the bests for the alleged cumpuon.Any.vlolauon of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of .3 .dIQ`�I1�erO 0 Occupancy Type
not more Nan five huridned dollen($5004
I,az owner of Ne properly,or my employees with waI n az their sole compevadon.
will do me work end smmmuste is not intended or fmod for sale(Sec.]0/4,Business Required Inspections
and Proration.Cade:The Comracmes Lt.Law does tet apply to an owrter of q P
pmpany who Wildsorimpraw therson,and he docsauch work himselfm through his
ownemployeas,provided that such improvements arc not intended or offered foraale.If.
however,the Wilding or Improvement is mid within one year of Completion.Ne mncr-
Wilder will have Be burden of proving that he did not Wild or improve for purport of
ink.).
I,as owner of the properly am exclusively contracting with licused convecmn to
cfttinct the project(Sec.7814.Business and Pmlesil...Cade:)TIe Cmuacmr'a Li-
cense Law does not apply to an owner of property who Wilds or improvrs thereon,and,
who mnmc match projects with a eontrrtmr(s)licensed pursuant m on,Convectors&
Lice.e
E3 1 am cm nder Sec .B&P jjf��or thiro^
O e Date ,V� d
WORK g C 45ATIOl DEC AT
1 hereby elr�mt un r puW tY pc jury ore of owing declarations:
I huv pro will morin Section
n37M of the Lsb r Code.for
fw erfmar se Of th-
mtion,for
for by Section 3]00 of the Labor Code.(or the perfonmaOcc of IW
work for which this permit is issued. '
❑1 have and will maintain Workers Compensation Insurance,as myvirod by Section
3700 ofthe Labor Code,for the performance of the work for which this Permit is issued.
My Workers Compensation Insunna carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EKEMP ON FROM WORKERS
COMPENSATION INSURANCE - r
(Thusection need notbccompleted if the permit is fmmmhundred dollars(SIM)
ar kos)
I anifv that in the performance of the work for which this permit is issued,I shall not
employ any Nixon in any manner m az in become mbject in the Workert Compensation
laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Ccnifintc Of Exemption-you should
become subject in the Workers Compamation previsions of the L mor Coda,you mum
.J Z forthwith comply with such provisions or this permit shall W ddemed revoked.
ZO CONSMUCnON LENDING AGENCY
(-t Ihemby vRum thasthero is a..,in.lcmdini`agcay for lW perfurmana of
Is'7 the.,it for which this permit u issued(Sec.3097.Co.C.)
W
Under' Name
Name
9L. Lender's Address
VC) I certify 0.11 have read thio application and sate that the above information is
W. correct.I agree to comply with all city and county ordinances and sate laws relating m
p W building construction,)afiretand hereby authmFm representativessu , a this city to moo anter n^the
W aMc mo imemd property for impaction proposes. /
(—'G (we)agree m saw,indemnify and keep harmless tW City of cupenits against j'�
r/y liabilities,jud ments.eosuandexpenw which may in any way acerae again.said City b
C.)Z in c'.= a the granting of this Permit Date
APPLIC#NT U DERSfANDS AND WI COMPLY WITH ALL NO -PO Issued by:
SO ERE TIONS. / a
Re-roofs
1-1.o plicanVCon emr Dare
HAZ US TERIALS DISCLOSURE Type of Roof
Will the appliamm future building Occupant mom or handle hanNous material
ined by tW Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Code.Section 25532007 1 All roofs shall be inspected prior to any roofing material being installed.
❑Yes y�no
Will she Applicant or future Willing occupant use equipment or Devices which If a roof is installed without first obtaining an inspection,I agree to remove
nit hararmus air comm, Us defined by the Bay Aroa Air Quality Mwgcmcm all new materials for inspection.
DimiCO /$
❑Yes p'I Nu
Ih ad he hvaNnus nodo,olsm Nacrox naundcr Chapin G95mfthcCables-
niaHal S ctyeodc.Secumes 25505,25533 and 25534,1 undersand thmifthe Wilding
does n9(cwm ly haw a unmt.Net it b my responsibility m mufy ire upant the
myat me. Inch armissu eor.eemniWateoy Signature of Applicant Date
All roof coverings to be Class"B" or better
011ml famixed age I