05020129 PermitLp�
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CITY OF CUPERTINO��->u+'�:..'=
BUILDING DlvlsloN PERMIT
CONTR'A16 R INFORMATION
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R GD. DING ADDRESS:
FERMA CORPORATION
PERMIT NO05020129
10675 BAXTER AV
OWNER'S NAME:
PERMIT ISSUE DATE
1265 MONTECITO AVE
06/13/2005
E:
SANITARY NO. CONTROL NO.
(650)961-2742
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRdimce,SDECLARATION
I liansetl Chapter 9
Job Description
p
ion? affirm the) l am under provisions of (commencing
With Section 7g10) of Division 3 of IW Business and Pro(cuions Cade. and my license is
anno v"'\
in full force and cocci
ClassLica
`):
DEMO (E) HOUSE I
Date
Dale Conlracbr
ARCHITECTS DECLARATION
I understand my plans almll Would u public records
V �l
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affrm that 11. exempt form the Contractors License Lew for the
t� d p 9 ,meq, y a y
following mason. (Section )(131.3. Business and Profs iota Code: Any city or county
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which .,.I. a permit to e.nnruet, elm,. improve, demolish, Or repair any suumare
N�"-blp'I Ilps!-w IWryI-- J�d'tlyl lq\l\�J—��'1
prior to its issuance, also MxIt irm the applicant for such permit to File a signed statement
that he is hanud pursuant to He provisions of the Contrutur's Liam Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7") of Division 3 of the Business and Professions CMM) or
1 0 8 O O
that W is exempt Mitterrand and to buthged
hours for e alleexemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant in a civil penally of
APN Number
Occupancy Type
P y yP
not more Nan five hundred dollen (S500).
❑ 1,. owner .(,he property, or my employ.. with wages. Iran sale compcnuturt.
will do the work, and the structures is not intended or offered for sal. (Sec. 7D44, Business
and ProlessiO. Code: The COnmcmrs Llcease Law ti= not apply In an Owlet Of
Required Inspections
propsny who buildsorimpro eas Hereon,and who doessuch work himmifor through his
own employers, provided that such improvements are not intended or offered forsale. If,
however. On Wilding or improvement is sold within one year of ..,Ind... go ownc,-
W ilder wiB hale On Wrden of proving that he did n.t Wild or improve for purpose of
Sale.).
X 1, as Owner of the propcny, am exclusively contracting with licensed contractors to
conswct the project (Sec. 7044, Business and Professions Code:)The COntrctors Li.
telae Law does not apply to an owner of property who Wilds or improves themen, ad
who contracts for such projects with a contractor(s) licensed pursuant in the Contra ones
License law.
1 am exempt under Sec. . B At P C for this reason
Owner� p
W%'CO—ENSATIONCAATION
1 hereby affirm under penalty of perjury, one of the fallowing declarations:
1 have and will maintain aCcnificare of Consom to self-insum for Workeh Co ri er-
smion, as provided for by Section 3700 of the labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Werkces Compensation Insurance, a required by Section
37W of the labor Cattle. for 0. performance of On "A for which this permit a issued.
My Workch Compensation Insurance cannot and Policy number am:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(Thu section need nut becompleed if tbe p.,mil is future hundred dollars (SIM)
or l.s.)
I certify Nal in the performance of On work for which this Permit or issued, 1 shell not
employ any person in my manner m are c pet to On workeri Compensation
Cenificale of Exemption. you should
become subject in the Worker's Compensation provisions of the Labor Code. you Must
forthwith comply with such provisions or Nis penmiuhalt W deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm Nat Vert is a Construction lending agency (or the performance of
the work for which this permit u issued (Sec. 3097, Civ, C.)
Lender's Name
,
Lender's Address
"
I renify that I hale ,cad Nis application and sum Nal She shove information is
toner(. I agate he comply with all city and county Ordinances and slam laws mining In
bonding construction, and hereby auNonn repremmnivu tar this City to cher upon me
ahovetmemi.netl propertyort for purposes.
(We) as.c to St., indemnity and keep harmless On City of Cupertino against
liabilities.judgments,f aninspectioneexpenses
expens.which may in any way accroc again. said City
A ePLICA ncc of Ne granting of this
to granting
DNMIL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
WILL
Issued by: Dale
SOURCE REGULATIONS.
Re -roofs
_tea t �!_ rS 1 Afi <./ t4 / o c
Sig In. of AppiicanVConwc r Dam
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or tutu. Wilding occupant Mo. or handle ha roux material
as t'by the Cupenino Municipal Code, Cbapmr 9.13. and the Health and Safety
oder Section 25532(x)? NO
❑Yes sfa
All roofs shall be inspected prior to any roofing material being installed.
It.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applies., Orrmum building Occupant use equipment or devices which
Im.ruua air cum umi.ants as defned by the Ray Arta Air Quality Mamgement
all new materials for inspection.
District?
❑ Ycs )dNu
1 have mut the haraMousmamrials Iryuccomnuunder Chapter 6.95 of He Calif r.
ria Heahh & SafelyCMc, Sccdom 35505.25533 md25534. I undersuhd Motif the building
does not currently have a Imam, that it ie my mapansihility to nilly the Occupant of to
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All roof coverings to be Class "B" or better
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Sol I
Owner or authomed ascan
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