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CITY OF-CUPERTINO�'
BUILDING DIVISION PERMIT
�,CC1NTRA TQR INFORMATION -
,
FERMA CORPORATION
BUILDINGADDRFSS:
PERMIINO. 06080203
21135 HAZPT.RRo()K DR
O ER'S NAME:
PERMIT ISSUE DATE
EDITH ONG & JACK TANG
1265 M
SANITARY NO. CONTROL NO.
(650)961-2742
ARCHITECTIENOINEER:
BUILDING PERMrr INFO
BQ ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
- Job Description
hereby arum Nal l am licensed under provisions of Chapter 9 (commencing
with Section 70M) ofDivislon 3 of Ne Business and Professions Code,md my Iicetam is
is full pence andetraL
DEMO SINGLE FAMILY DWELLING
Lleenm Class Lie. Y
Dau Conlracmr
ARCHITECTS DECLARATION
1 my CHIT W TSused as rte«N
undcrstantl plans public
\�
Licensed Professional
DECLARATION
Oat
I am cUIIDER
I hereby .(Seco Net 1 LleCOm Law for tbo
mempt from tW [assns
o
following mama. ] 1. and Professions Code: Any rity Of county
onstru t. after.
which requires • permit m 0onswcL aloe impmw, demal W, or rtpoh any swcturo'
permit t
prior at its imwme, alw nimmat the applicant for such permit of filea signed suumem
Ft. Floor Area
Valuation
that W is licensed pursuant the provisions of ftConttmt«'s Lions Law (C'hapter9
Sq.
(commencing with Section ID)0) of Division 3 of the Business and Professions Code) or
that he is eananPt Therefrom and Be basis for she alleacd esemptian. My violutlon of
r
Occupancy Type
Section 70313 by airy applicant far a Permit subjecs Ne applicant m • civil penalty of
eat mom than five luuttdzed dollars (5500).
❑ I, u owner of the property, or my employer with wags u their able compensation,
Required Inspections
will do the work aM Oar smam. 6 not Intended or Wooed for sale(Sm. 70H. Business
and Profession Code: The Certificates License Law dos ant apply m an own« N
q P
property, who builds m improves theaaten, end wH does such work himself orthrough his
ownemployces, tumbled dausueh improsnmmta ase out Intended oroQcrtd for salt It.
however. the building Or Improvement is mid within arc year of anmpletion, dre owner.
builder will have the burden of proving that he did not Wild or improve for purpose of
tale.).
��'!!1, u owues of the property. am =elusively contracting with licensed cbntrmtars th
(oMwct Ne project (Sec. 7044, Business and Professions Cade:) The Contractors U -
crone Law dam cot appy m an owner of property who Wilds in Mpmves mareon. and.
who contracts for such projects with a conuanor(O licensed purmam to the, Consommes
License Lave.
amm Punder see .B&Pcffo u n
J 0
weer Date
ORKER 0ATIO D LARAT10N
,
I mby affirm under penalty of perjury one a the following declarations:
bawdmIleeffivYlnCartiamafrensmoto If-itu
mambeforWurmesC«npen-
tation, uprovided for by Section 3700 of the lobo Cade, for performance perfannce of Ne
work for which this permit is Limited.
❑ 1 have and will maintain Workers Compensation luurance, u enquired by Section
1700 of NO Labor Code, for the pefformmce of the work for which this permit is Issued.
My Worker's Compensation Insurance comer and Polity number art:
'
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
'
Inds section reed notbe completed If 1W permit is (inane hundred dollen (3100)
or less.)
1 ceNfy Nat u the perr5ymonce of the work for which this permlt is Wised, l Nall oat
employ any Person in 4R) s"net aoI W o e h' ydo the Works ' ampema0an
Laws of California. D is
k pill mnt
NOTICE TO APPL Nr: If, a ct mak s e t tmm or Escitiptiou. you mould
became subject at the Worker. Campewtian provisions of Of or Code you most
forthwith comply with such provisiau or Nu permitmall Wdtt dnwtrd.
CONSTRUC710N LENDING AGENCY
1 herebyich thi then Nem h a ronSme 30 lending agency far the perfortnena of
)
work for which Nu permit 4 Wand (Sm 709], Civ. C.1
Lenders Nurse
Le
Lcndeh Add.
I «nify that I have read this application sad more that tbo above information is
conett I agate to comply with all city and county minames and suss laws relating to
building construction, and hereby authorize representatives of this city to enmr upon the
above-maMuned property for inspection purposes.
(We) agree to saw. Indemnify and at harmless the City of Cupenlna against
liabilium.judgmentacoss and expenses which may N my way mcruc against Old City
in consequence of the granting of NU Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Signature or ApplimDau
US MATERIALS DISCLOSURE
HAZARDOUS
Type Of ROOF
WIII Ne er forum Wiling accupaptstoro or MMIC mamrisi
a Cumnt
Health
u defined by the Cupertino Municipal Code. Chapter 9.13. and tW HCmN and Wery
Section 3553ua)+`'
All roofs shall be inspected prior to any roofing material being installed.
❑Yat IANu
If a roof is installed without first obtaining an inspection, I agree to remove
Win the applicant or future Wilding Occupant use equipment Or devices which
L 11AZWOus air contaminants as donned by the Bay Area Air Quality Management
all new materials for inspection. a
nusulict?❑y.
ICode.
IH thehvaNansmauriaU tee un.95ofdxCalifor-
cal S cryCade.Sttvons 3350 573 antl255 .luntic Natif dm Wilding
s eat c w a mnan4 Nat It myrmpomibil ly th nod eccupantfirtmc
h bo o^ arttter. Nram P9'730
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner 1
« Odac agent Dam