04120124 (2) CITY OF CUPERTINO .a .v c '� .�9'.«« ,A�.;.. +?'
BUILDING DIVISION PERMIT ONT�iCI'U ANFS.C)Y2MATION
,� r
BUILDING ADDRESS: FERMA CORPORATION FERMITNb4120124
20366 TOWN CENTER IN iff;
NER'S NAME: PERMIT SUE DATE
1265 MONTECI 7 2005
Or NE: SANITARY NO. CONTROL NO.
(650) 961-2742
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
1= 0 I=
+�s o ij LICENSED CONTRACTORS DECLARATION
+� 1 hereby afnrm that I Are Job Description
licensed under provisions of Chapter 9(commencing p
t1 with Section 701p)of Division 3 of the Business and Professions Coda.and my licemek
I.full fume n'g z ane
LkettuCl
Ue,0 DEMO
Dam
Combacler FFanA
1F2e T ARCHITECTS DECLARATION
1 understand my plans shall be used as public tecards
3 Licensed Professional
OWNER-BUILDER DECLARATION
+� 1 hereby a?nn that I am exempt form the Communes License IAA,for the
1:0 o following mann.(Section 703 1.5,Business and professors Code:My city or county
$ which real a rami,to construe,,alter,marrow.commit.m repair say structure $26250
FS't^ prior an its itsamm.Al.recolocA the applicant for such Permit to file a signed Wtemml
�o that W is Immecd pursuant to Ute prousiou of the Commbu's Umnac lAw,Chepter 9 Sq.Ft. Floor Area Valuation
$ (conore ncngwith.%Mion7000)of Div on3ofiho Busincuand Professions Cnde)or
taw he k exempt mmefrom And the basis for sec alleged exemption.Any violadan of
Sedan 7031.5 by any applicant for a permit subject,the applicant to a civil penalty of
net roam roan rte hundred dollars(SM. a Occupancy Type
❑1,u mmter of the pmpeny,w my employm with wgu u arch ark compenudon,
wtB do tau work,and thestmcmm Is nctinknded mortared for sale(Sec.7016,Bounce
And Prefessiens Cade:The Conuumh Lim se LAW don rot apply he An,owner of Required Inspections
property who builds or improves,her am,end who does such work himself ar Nmugh his
own employees,provided that such improvements mono,Imended wonered Im sam If. ,
however,the building or Improvement is sold within ane year of mmpletiaa.the owner.
Wilder will have the Wrden of proving that he did not build or improve for purpose of
sak.j.
❑1.as owner of the property.am exclusively emanating with licensed mmlamen be
construct me project(Sec.7064.Business and Professions Cade:)The Conuamees U. lt,
cove Law does not apply to an owner of property who Wilds or improves thereon,and,
who canmacla for such projects Wim a mnaacmr(s)Iimved pursuant to me Oonuac,ors
Lkenm Law.
❑IAmexemptunderSec, ,B&PCforthtsmuan
car Data
WORKERS COMPP.NSATIONDECLARATION
1 hereby allium under penally of perjury am of me following declarWons'.
1 Wveand A,Ili mumesaCmdr mafCenseuam16WureforWoderACompcn-
-lion,u pmvidcd for by Secdon 3700 of the IAWr Cade,for W parfm omen of tite
Werk for which this permit Is Lashed.
❑1 have and will maintain Workers Compensation losurnwc,ss required by Sccuon
3700 of the Labor Coca,far me parro mance of the work forwhich ark permit is Issued.
My Workers Compensation lnsunnce miner And Policy number Are:
csoim: STAre FUND PolicyNo,: C'7 tt 6jti3-v4
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This=!an need not hecomplelm time permit k forome hundred dollaus(SIM)
or tett)
1 certify that in me performance of me wad for which this permit is issued,I shall not
employ any person in any Ammeter so u in how=subject in the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT.If.after making this Certi@:ate of Exemption.you mourn
become subject m the Wmimes Compensation provisions of me IAeor Codc,you mum
.,O forhwith comply with such provisions or aria permit shall W da mW emotions.
z-0 CONSTRUCTION LENDING AGENCY
E (Macey affirm that mem is.mosuuctinn lending Agency for me Performance of
> the was for which this permit Is issued(SIX.3097,Civ.G.)
fL1zlancer's Name
z Unders Address
U0 1 mnify that 1 have read this Application and sum the the W.tnf.m.Is
FCmmm.I agate m comply with all ally and seamy ardi.T.and mate laws anteing m
DU Wilding convection.Ana hereby author=mpremmadves of this city to enter upon lM 't_t\�/t (y/ag�///t r V
417 Property for depenams purposes.
hichma ��
gk, (We)agree m ow,indemnify mid keep harmless the City of Cupertino against
fA Ilabilluu,jWgmenu.cosu udexpensos which may in any way ncerca against said City
t)7 In eonsalumm of me granting this Perosis
A 101
APPLICANT UN RST S AND WILL C P WITH ALL NON-POINT Issued by: Date
SOURCE REG TI
Re-roofs
Signa pplicanuec
Canumr % te
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant m future bW(tling cacuWntsrorc or handle hmsstlo.material
u denned by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
etle.Ones 255320)?
1$No All roofs shall be inspected prior to any roofing material being installed.
Yes
FWill the applican,or future Wilding occupant use equipment or devices,which If a roof is installed without first obtaining an inspection,I agree to remove
-11 huANnus air contmniunu as defined by me Bay Arca Air Quality Management all new materials for inspection.
DIWIct7
Yes WN.
I have mad the l uacdms materials requirements under Chapter 6.95 of the Califor.
nix Health&SafctyCude.S5uxm 75505.M533 ami 25534.1 un icrsuM that free Wilding
data nm conend haw a tenant thWooty m Wdfy due occupant of the
mquimmcn u�t Is pC211caae of Oce
Signature of Applicant Dale i
O authmi.dagcat te All roof coverings to be Class"B"or better