04120125 CITY OF CUPERTINO
BUILDING DIVISION PERMITV�1\iLI[H1710R�TN1�'Oi1VIA' I�N" b'
euaDIN3 ADDRESS: FERMA CORPORATION I IMITN'04120125
NER'S NAME: PERMIT IS6UB DATE
NE: SANITARY N0. CONTROL NO.
650 961-27 2
ARCHITECT NGINEER: BUIIDINO PERMIT INFO
BLDG ELECT PLUMB MECH
0
iso
LICENSEDCONIRdunder CONTRACTOR'S DECLARATION
uereby0)ar Nat1amlicensedunderpmvWoesofCWptera(commencing lob Description
with Section 7IXIU)ofDividon 3ofthC Badness and Profeuioes Cods.Wmylicense h
u
In full force and efrem. 3 3 DEMO
L,Z i avc Clan
D
3 Date ComI'S DECracmr
ARCNITECORATION
I undermmd my plans shall he used u puNic¢ends
5 ] Licensed Professional
OW NER-BUILDER DECLARATION
$ I hereby aRrm
that I em exempt from the Conuanores License Law for the
0 o following mason.(Section 7831.5.Business and Pmfeadum Code:Any city or county
$ which rm dr,a Permit to erutan alms.improve.demolW,or mpdr any mounter
FZ " poor to its issuance,also requires the applicant far such permit to rile a signed micracnt
gg <
that he is licensed pursuant to me provisions of the conlracmrs Uncnse Law(chapter 9 Sq.Ft.Floor Area Valuation
$ (commencing with Section 7000)s Division 3 of flue Business and Professions CMe)ar
that he is"--sept therefore and the bests for the,alleged Contraption Any violation of
Section 7031.5 by airy applicant for a permit subjects the applicant in a civil penalty of 3 6d�FDi®193�e10 0 Occupancyrt,
not mom than five hundred dollars(M), Type
❑I,u ownerofthe pmpny,ormyemploy,s with wages utheomlc Compensation,
will do the work and the muctum is rotmteMed ara@nd for We(Sec.70N,Badness
and Pmfesdoes Code:TU Comsodmrs License Law does rot apply se an owner of Required Inspections .
pmNny who builds or lm prow,Noose,and who dues tech weak hMadr or through his
own empWye<s,provided door such lmPrnwmante son mat intended soffsW ferule If.
however,the Wilding thug or Improvement Is mid within one year of compv for the owner- \
ues.). M0 Nve du burden of proving out ue did rot bWld or improv for purpose of
aam.I.
co f,son mvrcr of n property.am exclusively Business and conuesint with:)The Cconhanesa U.
S
cense La thees not (Sec.on an weer of andrty who ties Code:)The es theram.and
C
who lawdoesoroapply jets ownerorproperty who builds licensed pursuant
thereon,and
whonse Lace for such ryakne with econuacmrtal licensed punuam m the ContranoM1 \J
License Law.
❑lam esanpt undo See .Bh PC fm this recon
ner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury aro of the following deeluulons:
1 have and will maintain aCeNfiateofConsemm self-imam for Wskers Compen.
sstion,u provided For by Secdon 3700 of the labor Cade.for the performance of de
work for which this permlcla issuod.
❑I have and will maintain Workers Compensation Insumez,ss required by Section
3700 of the labor Code,fm me performance of Ne work far which this permit is issued.
My Workers CompemNon Inmmrce cams and Policy number are:
Cartier. Srnrc FUND Policy No.: 5 ,Ili l-04
CERTIFICATE OF EKEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(rho auction teed nothecomple ed if flue permit is fnrom hundred drllan(SIM)
s las.)
I cenify mm in the perforamme of de work for which this permit is issued,l shall not
employ any person in my manner an u to became subject an the WorteK Compcmmon
Laws of California,Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to me Worker's Compensation provision of the Labs Code,you muss
,J 0 forthwith comply with such provisions or this permit all Ise dm
eeed revoked.
z CONSTRUCTION LENDING AGENCY
[--i hereby which rat that them oarnmVuctlnn lending agency for me Performance of
Gi the work fn which tido permit Is issued(Soc.3097,Civ.C.)
QLenders Name
Z)
r7. Z Lender's Address I
U0 I=ify that 1 have mad this application and soon thu the above Infatuation is
0^ Woking 1 agree m comply with all tlry and county wafives of and rote hwa relating m
pg`'J' building codomctionmd hembyec0on proses. ves of this renter upon oM
W am filo" udgm property for a pe ason purposes. V w^�[/ug/�/
(We)agree m safe,Indemnify and keep interim me City of Cupenino against
fro incoisegence o ft trmandcfpeeseswhtch may In my way acture agdnsl said City
U APLICANT NDPRantingaf mo permit.
F7 APPLICANT UND RSTA AND WILL Y WITH ALL NON•POINT Issued by: Date -
SOURCE RED 0
i os Re-roofs
Sitnm pplicanUCantract, r te
xnzARDou TERIALS DISCLOSURE Type of Roof
Will the applicant or future Its ding occupant inose or toalle huudou materisi
as deRned by the Cupertino Municipal Code.Chapter 9.11,and the xeslth and Safety
AWLr'd..SSadoX No
con25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Y,
Will thea Ircant or future building occupant am If a roof is installed without first obtainingan inspection,I agree to remove
PP t p equipment m dMana which p g
7DIwic,7
hanrdam air contaminants u JcMcd by me Bey Area Air Quality Management all new materials for inspection.
❑Yea $iNu
I have MW the hanNousmaterials requiremenm undcrChapter6.95of the CalifonH,Ith&SdenyCade.Sectian3E50'25533 and 15534.I ands thatifthe building
not eunentl ,raffia kte[rmmsm-.mat it u my reapaed oilyIlse occupant of Ne
iremenk gd�yrwlmaanea .maraapm Signature of Applicant Date
o aamadsd.gent / Do All roof coverings to be Class"B"or better