04120122 CITY OF CUPERTINO t'2"' +xEnwh +.':tsk� �* '57*=a'>t ''
BUILDING DIVISION PERMIT fCONTItACTOA NFORMATION'�"�'
BUIL DING ADDRESS: FERMA CORPORATION 111N"b4 12 0122
W NER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY NO. CONTROL NO.
(650) 961-2742 ARCHI7ECTIENGINEER: BUILDING PERMIT INFO
BLDG EISCI' PLUMB MECH
:tel Op LICENSED CONTRACTOR'S DECLARATION Job Description O
('� 1 hamby affirm Nal I am licensed under previsions of Chapter 9(commencing p
,� with Section 70(18).(Division 3 afar Dual.and Professions Case.and my[I..Is
in lull rams end an«t. a3(33.7 DEMO
H E Lkenm Clue LIc.g
O Dau /� a r
Conuwr FQLMA A
ARCHITECTS DECLARATION C. \
I command my parts shall M used u public menta
c
Licensed Professional
OWNER-BUILDER DECLARATION
2 1 hereby aRrre that I am exempt freer 0e Contractor's License Law for the
a O O following reason.(Section 703 1.5,Business and Profesdotn Cade:My city or county
u$ which nwuirn a permit in construct.alter.Improve,demolish,or repair my mocmm
FZiw poor In its issuance.aim rcquirn the applicant for such permit to file a signed statement
gg G that he4licensed percenttotheprovisions ofthe Coruacmr4LlcenmLaw(Chapter 9 Sq.Ft. Floor Area Valuation
$ (rnmmcrrcing wide Semon 70013)ofDivision 3 of the Budoem and PmfcW..Cade)or
Wt M 4 aempt"we from and de bads far the dinged..pd..My violation of
nodi mo7031.5 ms Nan Tnveb Mad dooit.n iiSmL hwhjeela the applicant to.avilpem.ur or 3694EMAdbet00 Occupancy Type
❑1,as,owner of dm property,m my employee with wages u thebmle cosepenution,
will do the work,and themucture Is not intended oronered fm Wo(See.7044,Business
and Profewmu Code:The Conlrmurs Lulus law does at apply or an owner or Required Inspections
propeny w ho builds to improwa demon,and who does ouch wank himseir m through his
awn employes,provided Nal such Improwmema ere not intended oroftered total&If.
ha alver.the building or improvement is sold within aro year oreemple ion,the owner-
builder MU have dm burden of proving out W did rot build or improve for purpose of
sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors,to
conswct dee project(Sec.7044,Business and Profnsaions Code:)The Communes LI-
cenw law does not apply to an owner of property who builds or Impreves thereon,and
who contracts For such projeco with a eonuactor(s)licensed pursuant to W Contractor's
License law.
❑I ser memo[under Set ,B&P C far this moon
neer Dau
WORKERS COMPENSATION DECLARATION
1 hacby arum under penalty of perjury two of de following declarations:
I have and will main Wn a CertlOnw of Consent to self-iuum far WmkelsComport.
satlan,u provided fm by Section 3700 of dee labor Code.for de performance of the
work for which this permit if Issued.
❑I Aave and will maimdn Worker's Compensation Insurance,u required by Section
3700 of the Labor Code.far the performance of dee work for which this permit is Issued.
My Warkeos Compensation launna carrier and Policy number see:
Cmn� Za PVNQ Policy No.;
571�k61y3-
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This man.need not W completed lithe parmil4Imam Wrolo ddoNn($100)
or tesa)
I cenify that in the performance of the work for which this permit 4lssued.l shall not
employ any person in my mmnerm u to become subject to the Worker'Compensation
Laws of Calif tleaL Dam
Applicant
NOTICE TO APPLICANT:If,after making this Canifine of Exemption.you should
became subject m the Worker's Compensation pmviuons of the,LaWr Code you raw
.JO foMwithrnmPly with tech Provisions mthis permit Mail M deemed revoked.
z CONSTRUCTION LENDING AGENCY
[-t I hereby affirm that were is a construction lending agency In,the perfarmance of
DG the work for which this permit Is iuued(Sae.3097,Civ,C.)
W�Q Icndart,Namc
n7. z Lender's Aedma ,
V Q I certify that I ban mad this application and sue that the show Information is
0 arrecL I epee m ceand with y city and county marmwef and cute laws r Wing re
Q building construction,dersdand fembyauthmimmprtenutiws o(th4ciry le color upon de
y{Ll ahaw.mentl AS propene fm Wpecdan keep
(n (arc)ogee b raw.Indemnify and kap harmless the City m against
ts¢dinar
y4 Inconsegjudgments.the Sw ng at_ap es..L may in ane way seems agdnstsud City
U'+ APPLICANT WDERSTANDSS AnND WILL.CfIMPE5 WITH ALL NON-POI
SOURCE ULATION Issued by: Date
R 7 dS Re-roofs
gra afApplicenVCanlncurI Data
HAZARCHOUTMATERIALS DISCLOSURE Type of Roof
Will the applicant or future building escalator nom aremu le h wareousmaLLMai
U darned by the Cupertino Municipal Code.Chapter 9.17,and the Health ad Safety
ode.Secdan sss3z(.)7 ON. All roofs shall be inspected prior to any roofing material being installed.
❑Ya
WIII that applicant
If a roof is installed without first obtaining an inspection,I agree to remove
or future building occupant tee equipment or devices which
Knit haardous air conumlanu u dc8oed by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yrs AN.
I hew mad the haudous claedals requirements under Chapter 6.95 of the Cil ifon
nu Health&Safety Code,Schou 235115.25533 and 25534.1 ondcruaM that tribe building
does not currently have a makes.that It 4 my nespo9Rbility to unity de occupant of the
mquimmcnu mu 4met pride! dr a Ccmficam of OccupmcXSignature of Applicant Date
°
mthodred agent g
All roof coverings to be Class'B"or better
Ow / D