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CITY OF CUPERTINO
BUILDING DIVISION PERN
L?�Ry
BUILDING ADDRESS:
FERMA CORPORATION
PERMIT N
O05020129
10675 BAXTER AV
OWNER'S NAME:
PERMIT ISSUE DATE
1265 MONTECITO AVE
06 13 2005
PHONE:
SANITARY NO, CONTROL NO.
(650)961-2742
ARCHITECT/ENGINEER:
BUILDINGPERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 70(w) of Division 3 of the Business and Profession% Code, and my license is
in full force and effect.
DEMO (E) HOUSE
License Class Lie. M
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
following mason. (Section 7031.5, Business and Professions Cale: Any city or county
which requires a permit to construct alter, improve, demolish, or repair any structure
`
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
1 0 8 O 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy
P y Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars (S500).
O 1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work, and the struclum is not intended or offered for sale (Sec. 7044, Business
and Professions Cede: The Contractors License Law does net apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
g1, as owner of the property, am exclusively contracting with licensed contractors to
concoct the project (Sec. 7044. Business and Professions Code:) The Contractors Li-
ccnse Law does not apply to an owner of property who builds or improves thereon, and ,
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
"
❑ 1 am exempt under Sec , B & P C for this reason
teAON
hereby affirm under penalty of perjury one of the following declarations:
O 1 have and will maintain a Certificate of Consent to self-insum for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
O I have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becompleted lithe permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner so tp s}tb- t to the Workers' Com nation
` f ��� `r �
Exemption, you should
become subject to the Workers Compensation provision of the Labor Code, you must
forthwith comply with such provision or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction lending agency for the performance of
the work for which this permit is Issued (Sec. 3097, Civ. C.)
Lenders Name
Lenders Address
I certify that 1 have read this application and state that the above information is
correct 1 agree to comply with all city and county ordinances and slate laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above -mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Dace
SOURCE REGULATIONS.
Re -roofs
Type of Roof
/--,, .4-,2
Applicant/Contrac r Date'
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code, Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yes rid No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
O Yes -AdNo
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sccdon 25505, 25533 and 25534.1 understand that if the building
does not currently have a tenant, that it is my responsibility to notify the occupant M the
requircmentswhich bemet prior toissuance ofaCcnificateofOcrcupancy.
Signature ofApplieant Date
qmust
r- 131:4 �`',I— 131 05
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All roof coverings to be Class "B" or better
�'/L-
Owner I
or authorized agent Date