04120126 CITY OF CUPERTINO77777777777777077g, •� ��s:-` "a :' • �
BUILDING DIVISION PERMITCOIVTRA.C�t)R�1NF0;U1�11.7,TQN :,
BUILDING ADDRESS: FERMA CORPORATION ......04120126
NER'S NAME: PERMITISSUBDATE
ONE: SANITARYNO. CONrROLNO.
(650) 961-2742
ARCHnIIC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�f O C LICENSED CONTRACTOR'S DECLARATION Job Description O O
f1 I homey Affirm Nn 1 Am Imitated under provisions of Chapter 9(Commencing _
with Section 7")of Division 3 of the Business and Rofeuiom Code,And my license 1.
in full fume And eRecl
JIa Lmenmclas Lie.a , 3.27 DEMO
DA0 ContractorFfnokMfl
ARCHITECTS DECLARATION
I understand my plans Wail W used As public records
S 8Licensed Professional
OWNER.BUILDER DECLARATION
MI hereby affirm Nal I am ucmpl from the Conumctors License Law for the
O O following malnu
reason.(Section 7031.5,Bus and Profession Code:Any city at county
5$g which"unrest.permit mmuu
Cac4 altar,wepmw,demnlWm, repair my suuelmn
Err prior units issuance.Alsumquires the applicant forsuch permillo file aalgnedsummenl
th&the Hllccmcdpurmantto0npmvisiamof Nc Conmwr''sL¢melaw(Chspa9 Sq.Ft.Floor Area Valuation
(commenmcing with Section 7000)of Division 3 of the Business and Profusions Cade)or
that he ewnpt demfrom Aud the basis fm tiro alleged cumption Any violation of
Out ion 7031.5
Owmy
ndrtdldolWs r a per.II mbjecu the applicant N a civil penally of 3 fi4FDI�197�e10 0 Occupancy Type
❑1,u Owner of the property,in my emplowu with wages As their solo compensation,
will Pi f won,andthemuCmrt aLaw it foam apply to An Business -
Aud Pmfualom Code:TheContractor's
esthennum ndwho law urea or Apply to an owner of Required Inspections .
Own ewho builds oris prow Neimpr andwha measauebwork"Offeror through Ms
own employ=.er.the
provided that such imprawmw t are n s mar tied mo@md forsale.Own if.
builder,tiro building or impmwmmt 4mld within ane Sear o(mPrOWf r theOwner.
of
builder will low Na burden of proving Nu k did ml bWld m Improve far purpose of /J
um.).
❑1,es..or of the property,,Business e a d contrssi ng with:)The Co mrmlon m
came La tin project(Sec.70th,werofAnd property
who ui Code:)The Cmireman, rid s1+
ttmC law doss not Apply m ts owner of property who builds or improwa Corenn,and
who aces for such projects with aeontrclortd licensed pursuant mNe ContmTofs
0 l ail Law.
❑Tun uempt undo Sec ,BRPCfor Nisrwon
nor Dam
WORKER'S COMPENSATION DECLARATION
I hdmby LMM under penalty of pedury one of tiro fallowing decimations:
I haw and will maintain ACW Certificate of Consent to wif-imum fm WmlmfsCompen-
aslion,a provided for by Section 3700 of the label Code,for the performance of the
work for which Nb permit Is issued.
❑1 low and will maintain Workers Compensation Instuance,u required by Section
LAW,3700 of Ne lar Code,for the performance of Ne work for which Nle permit is lured.
My Workers Compemation hs..toric,Audi policy number ase:
Center. STATE FUND Policy Nm; S71 #614?-04
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thi$melon neN notboemnplemd If the permit Is foronc hundred dollen(Simi
or tut)
I Unity that in the perfarmAuec of the work for which this permit is Issued,I dull net
employ any person in my summer an As in become subject to that Workere CampemNan
Laws of CAlafuwL Dan
Applicant
NOTICE TO APPUCANT.If,after making this Cmillcam of Exemption.you Mould
become subject in the Wanu's CampemAdon proviaimu of the labor Cade,you must
.J O forthwith Comply with such provisions m Nis Permit be&=oil mmked.
z r CONSTRUCTION LENDING AGENCY
r�
F I hembyaththi Wtthart Is.
wed(mN 097,Civ,
agency for the performance of
W L e won for which this permit i$issued(Sec.7097,Civ.C.)
00.Q Landers Name
Q Z Landers"it=
U Q 1 Coldly that 1 haw read this applaeatim and sun that Ne&bow information 4
0^ COMM l agree to comply with all city and county.MfiM Of and sine laws rtlNng to J
O Wilding hereby
0ciMPs NmaampleaealAllwa Of this City VI Cnmr opnm the S
W
move-(We)areemendoned Warty(m(mnify An kwit1t
gyr (aju agree b cows indemnify And hcep may
In m w City of Cupenim against
a.lh inconsequengmenB,ms4Audeapemecemil. may In my wyscerue agalmt W6City
t)z
APPLICANT
T of DERSTingof�ltu parmil.
APPLICANT UND RSTA DS AND WILL CpppAMM{pppyy'(yITH ALL NON-POINT Issued by: Date +V
SOURCE liffiGpitillU Q / /
seen rt pplicmt/Conlramr / ,`/loth/ Re-roofs
HAZARDOu MATERIALS DISCLOSURE Type of Roof
Will No Applicant or future building Occupant nom or handle huardaus material
As de0ned by do Cupemno Municipal Code.Chapter 9.1x.W the Health and Safety
IDImict?
e,Section as3x(.n All roofs shall be inspected prior to any roofing material being installed.
❑Yu �Na
Will the applicant or future building Occupant use equipment or dcMaa which If a roof is installed without first obtaining an inspection,I agree to remove
t hanntous Air contaminants as de0ncd by the Bay Ares Air Quality Management all new materials for Inspection.
❑Yes �NO
I haw mad the bundmm materials requirements undcr Chapter 6.95 of Ne Califon
H=1"5afnyCode,Secdom255O5,25533mdx3534.1ende wrothalflhebmiding
tat curmndy A Nnitis mymspomty DutyNeoceupmtofdo
immen, primmW am ofOc Signature of Applicant Date
� aS
o dr athomadagm, i pm All roof coverings to be Class"B"or better