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CITY OF CUPERTINO
BUILDING DIVISION PERMIT `""°
CCTOR INFORMAU
BUILDING ADDRESS:
MC SOLAR ENGINEERING
PERMIT NDO 3 0 8 0 0 4 5
10436 MANZANITA COURT
OWNER'S NAME:
1168 ASTER
AVE
PERMIT ISSUE DATE
3
PHONE:
(4 0 8) 261-1211
1 /
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
1 hereby 1 licensed Chapter 9 (commencing
Job Description
affirm that am under provisions of
with Section 7000) o(Division 3 of the Busines, nd Professions Code, and my license is
in full force and U j
eff yt, �� �. ,X �,, f �
PHOTO POLTAI
C SYSTEM (2 KM )
License Class Ltc
Date J-' -' for j f't-i /_� -�O 0,/ -
ARCHITECT'S DEC ARATION
I un erst nd my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 703 1.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
00
prior to its issuance, also requires the applicant fur 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
3 426
1008.00
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of
APN Number
OCCU anC
Occupancy Type
not more than five hundred dollars ($500).
❑ I, 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
10T
—
1 d Inspections
and Professions Code: The Contractor's License Law docs not apply to an owner of
102
- PIERS
property who builds or improves thereon, and who docs such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
103
— UFER
however, the building or improvement is sold within one year of completion, the owner -
builder have burden he did build improve for
104
- REBAR
will the of proving that not or purpose of
sale.).
105
- ANCHOR BOLTS
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
10 6
- SEWER & WATER
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense Law docs not apply to an owner of property who builds or improves thereon, and
202
- UNDERFLOOR PLUMBING
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
203
- UNDERFLOOR MECHANICAL
❑ I am exempt under Sec. , B & P C for this reason
204
- UNDERFLOOR FRAME
Owner Date
205
- UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION
301
— ROUGH PLUMBING
1 hereby affirm under penalty of perjury one of the following declarations:
302
— TUB £s[ OR SHOWER
❑ I have and will maintain a Certificate of Consent to self -insure for Worker'sCompen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
303
— ROUGH MECHANICAL
work for which this permit is issued.
304
- ROUGH ELECTRICAL
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
3 0 5
FRAME
3700 of the Labor Code, for the performance of the work for which this permit is issued.
-
My Worker' Compensation Insurance carrier and Poli y number are:
�4�1 �0 5 - d 1
306
— HOLDOWNS
Carver: / Pn ,o.:
307
- INSULATION
CERTIFICATE OF EJf MPTION FROM WORKERS'
COMPENSATION INSURANCE
308
- SHEETROCK
(This section need not be completed ifthc permit is for one hundred dollars ($](X))
309
- EXTERIOR LATH
or less.)
310
- INTERIOR LATH
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
311
- SCRATCH COAT
Laws of California. Date
Applicant
313
501
- ROOF NAIL
- FINAL ELECTRICAL ENERGY
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
Forthwith comply with such provisions or this permit shall be deemed revoked.
502
- F I NAL PLUMBING ENERGY
'
503
- FINAL MECHANICAL ENERGY
' CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
504
- F I NAL BUILDING ENERGY
' the work for which this permit is issued (Sec. 3097. Civ. C.)
� Lender's Name
505
- F I NAL ELECTRICAL
Lender's Address
506
- GAS TEST -
j 1 certify that I have read this application and state that the above information is
507
- FINAL PLUMBING
' correct. I 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
FIN MECHAN CAL
ahove-mentioned property for inspection purposes.
0 9
FIN
(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
5
NG
' in consequence of the granting of this permit.
' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:5
WORKS Date
SOURCE ¢EGUL(Tle s.
-T7",'&
Re-roofs
Type of Roof
nature Date
HAZARDOUS MATERIALS DISCLOSURE
Wil 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 beinspected
prior to any roofing material being installed.
E) 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
cmil hazardous air contaminants as defined by the Bay Arca Air Quality Management
all new materials for inspection.
District? A
❑ Yes I Nu
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Heal th&Safety Code, Sections 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 of the
requirements ?ch mu be m : prior to issuance of a CcrtiOca of Oxcupaney.
Signature of Applicant
Date
*
All roof coverings to be Class "B" or better
O ner D to