09010121CITY OF CUPERTINO77
BUILDING DIVISION PERMIT
C�ly''�'�R, C3R 00.,
BUILDING ADDRESS:
PERMIT NO.
19333 VALLCO PARKWAY
FERMA CORPORATION
OWNER'S NAME:
PERMIT ISSUE DATE
PHO
A CONTROL NO.
(650)961-2742
A RC HI7-ECT/ENGiNEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC14
LICENSED CONTRACTOR'S DECLARATION
.
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70(0) of Division 3 of die Business and Professions Code, and my license is
ufull
C,��7 32-7
ABATEMENT, INTER DEMO & HAZ WORK; 200, 000SQ
enseq
Dale Contractor
ARCHrrECI-S DECLA TION
l understand my plans shall be used as public records
Licensed Prufessional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt rrum the Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to consuvct, alter, improve, demolish, or repair any structure
prior to is issuance, also requires the applicant for such permit to file a sighted statement
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commenting with Section 7000) of Division 3 of the Business and Professions Cadc) or
16 0 0 0 0 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
31620075 . A P L
❑ L as owner of the property, or my employees with wages as their sole compensation.
Required Inspections
will do the work, and the structure is not intended or offered for Sale (Sec. 7044, Business
and Professions Code: The Contractors License Law does riot apply to an owner of
q
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 said within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sa Ic.),
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon, and,
who contracts for such projects with a comractnr(s) licensed pursuant to the Contractors
License Law.
❑ I am exempt under Sec , B & PC for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure 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 Lssutd-
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued
'
My War Compeensatio cc carrier and Policy number are: 3 ��
Carrier. C 7 e !�/ )I PolicyNo.: 61'
CERTI�EXI7NFT104 FROM WORKERS'
COMPENSATION INSURANCE
(This section freed not be completed if the permit is for arse 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 as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is at 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 I have read this application and state that the above information is
con'ccL I Agra to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorim 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
liabilities, judgments, costs and expenses which may in Anyway accrue against said City
in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WiTH ALL NON -POINT
Issued by: Date
SOU REGULATI NS.
Re -roofs
Type of Roof
� e -2 -11 dY
Signawre ofApplicarit/Offitrwtor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle brrarddus material
as deilnod by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 2ss3z(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes � o
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? �
❑ Yea /`J "o
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor.
nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand that if the building
does not currently have a tenant dst it is my responsibility to notify the occupant of the
mqui nts wh..i.�ch�` be MCI prior to issuance of Cetirwate of occupancy.
Signature of Applicant Date
7=' ; 11? 1k"`7
All roof coverings to be Class 'A"' or better
Dale
Owner of Authorized agent