07020084 CITY OF CUPERTMIT
I1�10 I1FRM1TIfIN:
BUILDING DIVISION PER
PERMIT NO.
BUILDING ADDRESS: HORIZON ENERGY SYSTEMS 0 7 0 2 0 0 8 4
22468 PALM AVE
PERMIT ISSUE DATE
O'vNER'S NAME:
?RAKASH KASITYAP 440 SALTIAR AVE 2 7
SANITARY NO. CONTROL NO.
(408) 39`5-9060
BUILDING PERMIT INFO
ARCHITECT/ENGiNEER: BLDG ELECT PLUM M
ECH
ed a LICENSED CONTRACTOR'S DECLARATION Job Description
yV p I hereby affirm that I am licensed under provisions of Chapter 9(commencing
;z� with Section 7000)of Division 3 of the Business and Professions Code,and my license is INSTALLATION OF SOLAR ELECTRIC MODULES ON SFDWL
H in full force and,ffe✓ Lic.A y-3 ROOF
v�Z License Class
p Dam •6 Contractor
F m ARCHITECTS DECLA N
j e( t understand my plans shall be used as public records
)yU
u.y Licensed Professional
O e OWNER-BUILDER DECLARATION
'r 1 hcrehy alfirm that 1 am exempt Crum the Contractor's License Law for the
p O following mason.(Section 7031.5,Business and Professions Code:Any city or county
hich requires a permit to construct.alter,improve,dcmolleh,or repair any structure
a
-'w prior tri its issuance,also requires the applicant for such permit to tilt a signed statement Sq,Ft.Floor Area Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 $32090
i II--� (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
L that he is exempt from and the basis for the alleged exemption.Any violation of Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 35704075 . Number P Y YP
not more than five hundred dollars($500).
0 1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not 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 sate.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.).
0 1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li-
rty
o builds or improves
who contractLaw s for sues not ch ply to an owner of rojects with a coax cttoor(s)Whce�d pursuant to the Contractor's
License Law. &&P C for this reason
I am exempt under See.
Date
net
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the labor Code.for the performance of the
work for which this permit is issued.
0 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 Worker's Compensation insurance carrier and Policy number are:
Carrier. STA"�T FV A-* Policy No.: 3'31
L
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Cmis section need not be completed if the permit is for ane 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'Compcasation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z r. CONSTRUCTION LENDING AGENCY
(-r tNr I hereby affirm that there is a construction lending agency for the performance of
a> the work for which this permit is issued(Sec.3097,Civ.C.)
(L)Q Lender's Name
Lender's Address
1 certify that I have read this application and state that the above information is
U� correct.I agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction,and hereby authorize representatives of this city to enter upon the
above-mcnuoned property for inspection purposes.
a (we)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in anyway accrueagainst said City
U Z in consequence of the granting of this permit. Date
►� APPLICANT UNDERSTANDS AND WILL COMPLY WiTH ALL NON-POINT Issued by:
SOURCE RATIONS. 3^9f-0 7
�----- Re-roof;
Signa(W of Applicant/Contractor Dam Type of Roof
HAZARDOUS MATERIALS DISCLOSURE yP
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
ide,Section 25532(a)? All roof s shall be inspected prior to any roofing material being installed.
C3 Yes [jkN° If a roo7'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?
0 Yes Nu
1 have read 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
docs not currently have a tenant,that it is my responsibility to notify the occupant of the Date
requirements w ich must be met prior w issuance of a Certificate of Occupancy. Signatu"e Of Applicant
-9- 9-o7 All roof coverings to be Class"B"or better
Own orized agent Dat,