04120123 CI TY OF CUPERTINO
BUILDING DIVISION ;,.
PERMIT CONPRA �aQRINI' ATIUN
.al .;atff ,4•,d ;r'�z aesx' aray.,. ry.
amnINGADDRPSS: FERMA CORPORATION PE1IMRN"b4120123
NER'S NAME: PERMIT ISSUE DATE
CTC FUNDING. LLC 1265 MONTECTTO AIM
ONE: SANITARY NO. CONTROL NO,
(650) 961-2742
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
YOZp LICENSED CONIRACTOWSDECLARATION JobDescription 0
1 hereby affirm wl 1 am licensed under provWam
u of Chapter 9(mmmin
eg
i wids Section 7131d)orDiAMn 3 of the Business And Pm(esduu Code,and my license is
]� in full to.and effect. �36�3? DEMO
? License Chis Lk,g
L11-- Dam Q o Contractor FOFQrhA
q r / ARCHITECT'S DECLARATION
22 1 understand my plans Nall he tired As public Memo,
I4 Licensed Professional '
Gy OWNER-exempt R DECLARATION
ConTION
i I Meny.(Swi on I am exempt from u Professions ConoCo License Law far tM
i O O whicformh re rtasoa(section 703 str Busircas andve.duCade:My city or county
Z j which its sura•permit re construct,ahae Improv,demolish,or repair any awcmro
HZi pdaeitstssiamm.Alco,ensedprsuant the tMapions of for such pmmi'eicenserile a iLmdstsmment
gg$�(zFEp muheiaMcnscdpuwenteNoofDNinnsoithe oftheBraner4UcenseLaw(Chapter ode). Sq. Ft. Floor Area Valuation
669 (rot Zia exempt
Section7a00)ndthet taxisom for
oflheBwrcaa ptond n.Any vi Codc)a
a that he k vumpt therefrom and the bub for Ilse alleged exemptlon.Any vialadon of
Section 7031.5 by Lay applicant for a permit subjects the applicant in a civil penalty of
not mom man livehundred sonars(Lase). e10 0 Occupancy'Type
❑I.u mw of me ptopm y.m my employm with vngu a reek sok mmpmudon,
will do the work end,haswcem isml Intended aroffned forsele(See.7044,Businc s
and Prefcassiam Cadc The Conbacuses Liman law dans rot apply an an owner of Required Inspections .
propertywho build,orisoprow themon,end who do aauchwariihimself serIlwugh his
awnemployca,provided Ihusuc),improwmmts art not intended Warrants!fm sae If.
however,the building or improvement is sold within am you of completion,the must.
Wilda MB have the burden of proving that he did not b ild At borrow:fm purpose of
"In.).
❑1,As carrier of the property am eaclumnly contracting with licensed mnoacmm a /1
construct the project(Sm.7014,Business and Professions Code:)The Cmoaeer'a U.
cense law sou not apply a an owner of property who build,of improv thereon.and
who contracts for such projects with a con rsctarts)licensed pursuant at tin Contractors S
License Law. \�
❑1 am exempt under Sec. .B k P C for this moon
at Dale
WORKER'S COMPENSATION DECLARATION -
I hamby tlfirm under penalty of perjury am of the following declarations:
1 haw and will maintain a CenificaeafCoruent to self-insure(orwohers Compen.
salon,As provided rim by Section 370E of the labor Code,for the pedamunce of the
work for which this permit is issued.
0haw and will maintain Waters Compcuadon Insursna,As required by Section
of the Labor Cade,fa the performance of the work for which this permit is lasued.
My Worker,Compensation InmmKm cannot and Policy number art:
carder. 9-11HTA FONo Policy No.: S>f *6W3-04
CERTIFICATE OF F.KEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need oat beeomplemd i(the permit ls(arom hundcddolWa($100)
or ku)
I unity that in the perrmmance of Um work for which this petmlt is lasted.I Mail ria
employ anypeemn in try mmnerse As in bcmme subject to the Workers Compensedon
Laws of California Dam ,
Applicant
NOTICE TO APPLICANT.If,after mixing this Cenirram of Exemption,you should
Iacocca subject in the Workers Compensation provisions of the labor Code,you must
rJO foMwith mmply with such provisions a this permit shall he demand ovulate.'Z..'" CONSTRUCTION LENDING AGENCY
(.► I hereby affirm that there is•mruuunion lending agency far ft perfmmance of
C the work for which this permit Is issued(Sec.3097,Cih,Ca
W 0 lenderm
s Nu
0 .L Lender's Address
UQ 1ttpme Mal IMw read oristyapplication andtummu and
show information is
C) miming l agree ct comply were all city and aunty ntati emsa,nd atsu tsnt r u ont e
Q rV' Abovingcomwcdoamdhemmby aumodmrposes representatives,of this city menmr upon the
W ,have-menudgm property for impaction purposes /
n (We)em en a acs,indemnify and keep harmkv the City or Cupertino against
,..t rat Ilabllitia,judgments.eom and expenses which may In any way ammAgainst said City
U
inc as o(the gran. goS AND ma. Issued by: Date
APPLICANT GUMS AND V�CS"PLY
WITH ALL NON-POINT
SWRCT3 L ONs. -..
°S Re-roofs
Si ofApplicmt(Conwno Do
HAZARD S tv1ATFAlAlS DISCLOSURE Type of Roof
Will tho applicant or forum building Occupant time or handle huardous mamdal
As darned by the Cupertino Municipal Code.Chapter 9.12.and the HWM and Safety
axe,Scaties zss3x(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ya j$Nu
IF Will the applicant ser fotum building occupant axe equipman,a devims which If a roof is installed without first obtaining an inspection,I agree to remove
-it hitsmom air cmtsminams As defined by the Bay Area Air Quality Management all new materials for inspection.
DistricR
QYn $�No
I have mad me huankus materials requirements undcrChepmr6.95 of the CLIIrOr-
nlaHulth@ Safely Codc,Smdms25505.25533 and 25534.1 undamtsnd muifde building
dao rot cerrenti Mea mlrYr4 out It k my res riuh0rly m notify um oceupant of the
requiremcn must gioim`iu / d`CeniRest arampan . Signature of Applicant Date
z r > aS
raurhorissdescm g
All roof coverings to be Class"B"or better
_ m