04120121 CITY OF CUPERTINO '~ #k�'sxa 3'd'zt• abs x H* ' "„ .'
BUILDING DIVISION PERMITS+ };til[tf.��'T''tii7 ,ta'vAliYil
Bu1LDINGADDRESS: FERMA CORPORATION PERMITN"b4120121
NER'S NAME: PERMIT ISSUE DATE
NE: SANITARY NO. CONT0.0L NO.
(650) 961-2742
A0.CHITEC(ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I� o o l�
LICENSED I a CONTRALTO r pt DECLARATION lob Description
e hereby affirm that 1 am of
Bu under provuhms a!Cl de. 9 my It".(commencing p
VALE,Salon 70(of ecDivitlon]of de Budrcas and Profesdans Coda,and my licence t,
Inranto=mderca 236337 DEMO
Z
Lk
Chu Lic.Coli
gt� Dau CTSDECL FL2rv]A .
?S t
ARCHITECTS DECLARATION
'33333j$ I understand my puns NJI be used as public rtcorda
5 tad fir, Licensed Pmfcuimm?
3 OWNER-BUILDER DECLARATION
i q I hereby alTi m that I am exempt from the Conusnor',License Law for the
COO rellowlnl=$on.(SccMm TDI.],Business and PNRaalans Code:My city at county
u�$ which requires a Permit to cnnumct.alur.Improve,demnl W,a mpair my structure
FZ� prior m is Issuance,aim requires the applicant forsuch permit m Nes signed statement
zp tlW he 1,licensed pursuant in Me prevision or the ConVmmra Ummo!Law(Chapter 9 Sq.Ft. Floor Area Valuation
C� (commencing with Section 7000)af Division]o(de Business and Prorrulona Code)or
3 that he Is exempt bee""m and Ne basis
for the alleged mempdan.My violation of
SectionMore t anK h�aand a`anerm(3M),h mbjau the aPPlumt m a clWl penalty of.01 3 6641Q�ee0 0 Occupancy Ti pe
❑I,u oweerofthe properly,mmyemploytta with wguuthetrmlccmmpenutian,
will do the work and ueanasure utter intended croRered forsale(Sec.7041,Bus im,
and Professions Cade:The Contractors License Law data not apply m an owner of Required Inspections
propeny who builds or improves thereon,and who doessuch wok himself o though Ms
awn employcns,provided thauuch improvement,art not Intended oroRered forule.If.
howem.the building or improvement u mid within one year of completion,the owar-
builder .will have Oe burden of proving that he did WE Mid or improve for purpose of
ale.).
❑1,u owner of the property.am"elusively contracting with licensed mnuacters to /J
construct the project(Sec.70M.Business and Professions Code:)The Commences LI.
M=law does not apply m an owner of property who ME&or improve demon,and,
who comments for such projects with a ontrmmr(s)licensed pursuant m the Conmemh Q�
License Law.
❑Iast.mantueder Sec ,BkPCfathismamn
net Dart-
WORKERS
auWORKER'S COMPENSATION DECLARATION
I hereby at'll under Penalty of perjury am of the following declamfiou:
1 have and will maintain a Certificate ofComentto self-imure for Worker's Campen.
strum,AS pmWded fon by Section 77M of Ne Labor Code.for the Performance or the
work for which this Permit is issued.
❑I have and will maintain Worlues Compensation Insurance,as required by Section
3700 of the Labor Cade,tar the performance of the work for which this permit is issued.
My Workers Compensation insurance nmiu and Polirynumber art:
canner. T9- TF NAIL) Policy No.:S>1 #()443-04
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(nds maim,need not bo completed ifde Pamir i,farome hundred clothes(SIM)
or test)
I ctrufy that in the performance of the work for which Nis permit is issued,l shall net
employ any Perron In my mannerse u m become object to ds:Worbcd Compenutio
Laws of Califamia,Dae
Appliesm
NOTICE TO APPLICANT.If.after making this CenlOcau of Exemption,you should
become subject to Ne Workers Compensation provisions;of the Labor Cod4 you moor
0z forthwith comply with such proMsioru or this permit 0111 W deemed revoked.
zpy CONSTRUCTION LENDING AGENCY -
I"m^ Ihereby affirm that then is a couVuctinn kMing agency for the perfurmanm of
lk the work for which this permit is issued(Sec.3M.Civ,C.)
A Landers Name
7 Z Iander,Mdmu
U O I«rdfy that I have rad this application and sum this the above information Is
LX�0^ renes,I qrm m comply with all city and county matim of and st,k hw muting e
O SV^ how-mcndoned inn.and hereby mthorimrposes tivc,of this city mcnurupon Nc
W abova-mentiuned PmpenY fon Inspection purport
0. (We)agree to on.indemnify and keep Monikers the City of Cupertino against
y Inconsequence of
neared ax penseswhtch star In any wapttrve against mid City
U 7 In consequence of dm granting of this permit
rte• APPLICANT NDER NDS AND LCOMPLY WITH ALL NON-POINT Issued by. Date
sou"c Watt - j 4`j/� Re-roofs
S' eor Appli,mt'Cotnc/%// u �j-
HAZAR' ,US MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building receptor more or handle huudous rommal
as defined by Ne Cupertino Municipal Cock.Chapter 9.12.and the Health and Safety
Ini.
c,0Yeti 25572(e)7 �No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t huarmus air contammnsns u defined by the Bay Arta Air Quality Management all new materials for inspection.
lier?
❑Yes -KN.
I have mad the hamrdnus materials requirement,under Chapterti.95 ofthe Califor.
Hull”SarmyCod0.Scums 25505,255))and 25534.1 understand that if the building
not cure y have @mane that It 4 nskility m notify tie otupant of telmm hich rbc-mat prior eor.ccrileateofoccu . SignatureofApplicant Date
�1 7 p
o authonmd agent „/' Do All roof coverings to be Class m$m or better