04120128 CI TY OF CUPERTINO ��s,� xxy�ax �so-�• ».. y� n , '* �'
BUILDING DIVISION PERMIT If•�•�O 'AY � ��Oh
Bu1LDING ADDRESS: FERMA CORPORATION PE "'04120128
NER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY NO. CONTROL NO.
(650) 961-2742
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG EIF.(,7 PLUMB MECH
Z 0 I�
ijdF LICENSEDCDNnRd under$DECLARf ION
Chap Job Description
�x`F I hereby affirm Net I em of the
B under provWana of Chapter 9(commencing p
m< with SatieAdlO)of DivWon]ors the Badness and Pro(e.riumC and mylicenb
gin full farce untl eaecL 23C,�3� DEMO
? Dam— Chia I30.• .
As about use T. DECLARATION
i understand my pone dull be used as public scuds
5 �0 Licensed Professional
3 OWNER-BUILDER DECLARATION
1 hcmby affirm Net 1 am exempt from the Comments License Law for the
E o o following mama.(Sudan RD 1.5,Business and Pmfestiuns Code:Any city or county
$ which requires a Permit to construct,slur,improve,demolish,or repair any munum
Polar Or its issuance,shoo requims the applhcam forauch permit to files signed cabmen
ggzFFp tha ere is nand pursuant mum provisions of the conoactara Uwase Law(cnapmr9 Sq. Ft. Floor Area Valuation
d$ (commencing with Section 7a W)of Division 3 of the Busineuand Professions Code)or
a that he la attempt Nemfrom and the bub fes the alleged assumption.Any violation of
Section 7031.5 by any applicant foo s permit subjects tie applicant in a civil penalty of 3 691$et0 0 Occupancy
not rove than Roo 1uane hundred dollars(5500). p Y Type
❑L u owner of the propeny,ormy employees with wages u theirmle,noiss radon,
will do the work,end Ne suuctum is malmended oroQered for Wo(Sec,7044,Budnssa
and Profeadom Cade:The Conaacme.Llama Law don net apply m in owner of
Required Inspections
property who Wild.ar(mpaoms Hereon,andwho doetsuch weak himselforthrough hit
ownemployces,provided that such improvements am not intended mortared faulty If.
however,the building or Improvement is sold within one year of eompledon,the mover.
holder will have the bumen of proving that k did not bWld or improve for purpose of \
hole.).
❑1,u owner of use property,am coo usively contracting with luensed commerce:to
.=[.I that project(Sec.704/.Business and Professions Cade)The Comranor's U.
can law does not apply m in owner of property who build.or Improves thereon,and
who contracts forauN proJeco with a contractor(s)Ilametl pursuant to the Centranoh
License law. �)
❑loo exempt under See. ,B&P C for this reason
Dam
WORKERS COMPENSATION DECLARATION
I hereby aRm under penalty of perjury ane of the following declarations:
13CII000
ave aha will maintain•Cersifuau of Cement w self-imam for WortrtaCompen-
.u provided!an by Section 3700 of the Labor Code.for the performance of the
for which this permit is issued.
aw and will maintain Workers Compensation Imunnce,u required by Section
of esu Labor Cade,(a Ne performance of Ibe weak for which this permit is Issued.
orkers Compewuan Insurance carver and policy number art:
o STATC FANO PmlicyNa.: 571 #1.143-04
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This met.need Out becumpleuJ Kusa permit Is fare.hundmddo0av({101)
or bast)
I certify that In the performance of the work for which this permit Is Issued,I shall not
employ any person in my resonant an as to became subject to the Workers Compemaian
Laws or California.Data
Applium
NOTICE TO APPLICANT:If,Apar making this Cenilicam of Exemption.you should
become subject to the Workers Compensation provlsions of the Labor Code,you muss
0z forthwith comply with such provisions or this pertl mv
mit shall be doomed!
z 51 CONSTRUCTION LENDING AGENCY
(~ I hereby dorm then Nem is construction lending agency for the performance of
Ci
the work fur which this permit b issued(Ser.3097.Civ.C.)
GQ Lando',Name
0.z lender's Addneas
U O 1 cemly dot i have mad this applicaian and sum that the above information Is
coeoa I agree m amply with all city and county ordinances ad some laws melting in
0 building convection,and hereby authodre mprevmsuves of this city in enter upon the
purpo
W
above-menuuned property for inspection which ma V�"!f/kJ[Ja/ , /
G (We)agme to sow,indemnify and kap harmless the City of Cupertino against ^"� /
rW) in consequeneor thecmo and espensmitch may in any way accrue aga7mtsaid Chy L
U7 in PLICANaof esuBootingof u�bDWI
r� APPLICANT UNDE ANDS'AND WILL COM HALL NON-POINT Issued by: Date
SOURCE REGUL ONS �/_
_ � a);,/S Re-roofs
gignaurep p IiwnuConwcmr y"M �,�of Roof
C/ HAZARDOUg MA'PEgfALS DISCLOSURE
WIII esu appncam or forum building Occupant tom or handle hahordom meudai
u defined by Lou Cupertino Municipal Code,Chapter 9.h7,ad the Health and Safety
ede,Sudan 75533(.? All roofs shall be inspected prior to any roofing material being installed.
❑Yes [�No
WIII the applicant or future building occupant n equipmorl or devices which If a roof is installed without first obtaining an inspection,I agree to remove
II W ardnus air conumlmnu a donned by Ne Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yea Wit
I haw mad the haimou materials requirements under Chapter 6.95 of the Cdifon
niaHeatA cies SafetyCodc,Sa.0675515,35533 and 25534.1 Understand Wa ifua building
does not eunentl flan m4 that it boy re. Ihju In mall'y the aeunt of e
rryuimmcn bee dm ha ralmamerocc.1" Signature of Applicant Date
r aulhmiead agent i- Dae All roof coverings to be Class'B"or better