04120127 CITY OF CUPERTINO dmox , vfta p �y�y" �ys� ' y'y�7a�r' '
BUILDING DIVISION PERMIT 'hA1l.� lJ, s:- 01T. 11F!IJ+ AA"✓1V
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emI.DINGADDRFSS: FERMA CORPORATION PERMIT N%4120127
NER'S NAME: PERMIT E3UB DATE
CTC FQNDINQ- TIC 129; MON RCTTQ AIM.
ONE: SANITARY NO. CONTROL NO.
650 961-2742
ARCHTfECDEHGINEER: BUILDING PERMIT INFO
BIRO EIELT PLUMB MECH
o ij LICENSED CONTRACTOR'S DECLARATION
thereby )of WI1 3IfftRe anderprovWomof Chapter 9(commenelag 70b Description
with Sccdceande effect. 3ofW Residents add Rlo�feul/uru Code,and mylicense k
n Z Lkel,ie Ci,ind`H"` uc.g 1)�(, ?3% DEMO
DOW_T r� Contractor FE$Z .A
,e ARCHITECTS DECLARATION
y 1 undersand my puna a1Wl W used as public re molls
3
Licensed Professional .
OWNER-BUILDER DECLARATION
I hereby.(Sell mit I nm exempt!Nm the Contractors o :Any c ty o for the
i D 0 following waa.(SneJon]IDIS,Business and improve.
do au Cade:Any city or manly
$ which its iresism.pm011 m cor libee ellen Improve,de permit
T II repair any Nurture
Fater Tom he its iuumrn,dmm in The thdvisiocanf for Comoseud'sikimw III gnedaatemrnr
< thatheuccemed purmam In W provision nlWComrmmfand Professions
roessio(C Code)or S Ft. Floor Area Valuation
Fq�th (on hael..' to thection ditor,and
the hands
the
cu pt Profen vi Cnde)of q
Wt W k exempt therefsem and Ote beta(m We alleged exmnpJon.Any Woklion of
Section 7D31.5 by a"applicant fm.permit sebjeels W applicant in a civil penalty of 3 e10 0 Occupancy T
not mom than five hundred dollars(f3004 p y y�
0 I,an owner of W property.or my employm with vngu u Weir sets compensation,
will do W work,and The structure It not intended or offered for ask(Sec.7061,Business
and Prefeuiom Cad.The ConructarY Liceue law dm ant apply in an owner of Required Inspections
property who bulldsm improv Creon,and who doesamhwerk himulfor through his
own employm,provided thetsuch lmprowmenu art net intended muttered for ask,If,
however,W building or Improvement Is sold within one year of completion.W owner- C
Wilder will haw W burden of proving that he did not build or improve for purpose of f� ppp
sadick
❑L as Owner of the property em exclusively contracting with Ikerued conlraelan to
construct t project(Sec.7044,Businessand Profusions Code:)The Contractors LI-
mease v
come Law data na apply c m s ownof property who Wilds or improve Corton.anal
who contracts for such projeeta with•conlalicensedr(a)licensed pursuant The e ContContractors1.1cto1a.law.
0 1 am exempt ancien Sec. .B d:P C for this recon
InerDateWORKER'S COMPENSATIONDECLARATIONI hereby air=under perWly ofpodury ane of Ne fallowing Outstations:
haw and will real min•CartlOmmof Consent m self-isure fm WorkertCammn-
n,u provided far by Section 3700 of The Labor Cade.for Ce performance of W for which this pcnnit is issuedhave and will maintain Workers Compeuation Inman.,u required by Section
of Jen Labor Cade,far W performance of W work far which Cu permit is Wmd.
Workers Compensation Wurance artier and Policy number am:
er .STATE FUNO PolicyNo.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mm section need net bocompleted lithe permit uforarte hundmddo0ats(5100)
or kaa.)
1 cenify Cot in The performance of W work for which This Permit it issued.I"I nm
employ any person in any Warner an as in become subject toed Workers''Compellution
Laws of Califomi..Date
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Eampdon,you Mould
become subject to The Worker's Cmnpensatlon provisions of W Labor Code.You mute
OZ forthwith comply with such provisions or this permit shall k deemed revoked.
',y F-1 CONSTRUCTION LENDING AGENCY
(--r rte.. I bereby dRrm That them it a conmacJon lending agency for the perfermanm of
Nl? W work for which Cu mmrit la issued(See.3097,Cih,C.)
Q Under,Nunn
11. z Limier.AOdreas
C)Q 1 cenify Out 1 haw reed this application and spin that We above informNun is
correct.l agree TO comply with all city and county ordinamea and state laws mining ot
0 building construction,and hereby authorise representatives of this ity Cen¢r upon On
LTj aWw-mentioned property for inspection purP=L
ty,LL (We)is.to now.indemnify and keep hatmkss W City of Cupertino agaimt
liabil)Jes.Jodgmcnu,costa and expense which may in any way c= S.iMuid City
U in consequence of The granting of Crsrens Issued by: Date
^" APPLICANT UNDER NDS D WILL CO TH ALL NON-POINT
SOURCE RECU
03 Re-roofs
Signaw plieanVConlrsolor j^ D
HAZARDOUS MA IALS DISCLOSURE Type of Roof
WIIINeapplicammfurure Wlld poccupant nom car hendlchuudoua material
u dci ned by The Cupertino Municipal Code,Chapter 9.11,and W Health and Safety
alEJLThi0dc.So
�No n 23532(e)1 All roofs shall be inspected prior to any roofing material being installed.
yen
Will The applicant or future Wilding omuPant ane equipment or dcvim which If a roof is installed without first obtaining an inspection,I agree to remove
mit hanutlnus air conumiwra as dcRned by the Bay Arta Air Quality Management all new materials for inspection.
DINtsl1
❑Yea We
I haw mad W haurdlwa materials requirement under Chapter 6.95 of the Caller.
Smdonf25505.25533 and 23 N.�1Podm tehift Jx Wilding i
dm ml cuncnl! rt�was rLL[p�oom.Cel it 4 my m 'I lyre mdfy Cc occupant of W
m4ulmmen i,.,tyuuuma'ii 1pllarmlat9a "'ficaCaf Occupancy
C/�1��_ �G i a S. Signature of Applicant Date
amh.A.dagm Date All roof coverings to be Class"B"or better