04010047 CITY OF CUPER'PINO '"'C, 'r
BUILDING DIVISION PERMIT CONORINIFORMA.TION:,
euaDINC ADDRESS: REGRID POWER PERMIT No'04010047
OWNER'S NAME: - PERMITISSUEDATE
NE: SANITARY CONTROL NO.
ARCHDEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
Y00
LICENSED CONTRADECLARATION
U 1 the by firm Nat I am licensed and dProf sons Code, 9(commencing Job Description
n� with genion fecDivision)of Ne nJ Professions Code,and my license is
o, in full fore effect.
Ueenm as Lie.« ao2 SOLAR ELECTRIC SYSTEM (II ED
n F p Dam / ContracN - _
ARCHITECTS
IV,A AT
cediodmyplainshall he usedmm recnms
It, Lkenndpmfeaaian.l JAN 2 9 2004
OWNER-BUILDER DECLARATION
E 0 1 hmcby$(Orin on I em exempt from the Cnnlraeoo e:Any c Law for the BUILDING
p O following nuns Permian 703[.5,Business and improve,
demob Code:Any oily or county
K$ which requires n e,also re construct,eller,improve,demolish,ore a sir anygned tateme t
that heor its issuance,toomotquircs the provoi nsof forthe sucContractor's
iccow ave statemem
P (commencingWJpurstionto the 70shofDivision3oheCommcmr'aniccnulsw(Code)9 Sq.FL Floor Area Valuation
y N p bat he is examWith Section and de Division 3 of the alleged Business pt Profeon.Any va Code)of
y $ Nat he is exempt IWcfnm and dm beers for dm alleged exemption.Any it Penalty
of
notSection
rethanSby nmy erect for A wbjects the applicant to ecivil penalty of er Occupancy Type
not more than Eve hundred anion(esoo). 3�2��31� 0 0 P Y YP
❑I,u owner of the property,or my employees with wages u Neio sole compensation,
will de the work,and the wormer is not intended or offered for sale(Sec.)044,Business
and Proremmm Code:The Convenors License Law does not apply m an owner of Required Inspections
pnperty who builds or improves the......d who doessuch work himself or domain hia
own employees.provided that such improvements arc not intended or offered for sale.If. -
however,the building or improvement is sold within nae year of completion,the owner- _
builder will have Om burden of proving Nm he did not Wild or improve for purpose of
ask.).
❑
I.as owner of the property,am exclusively convecting with licensed contractors m
construct the pmjecl(See.1044,Business and Professions Cotler)The Contractor's Li-
cense Law docs not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a commensals)licensed pursuant to the Cmeb actoh '
Lkenae Law.
❑ l am exempt under Sec. ,B@P C for this mason
1
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain aConifieate of Consent to saIN..um for Workcr'sCompen-
mn.u provided far by Section 3100 of the Labor Cade.far Ne performance of the
work for which Ibis permit is issued.
1 have and will maintain Worker's Compensation Insurance,m required by Section
00 of be labor Cade,for the performance or the work for which this permit is issued.
My Worke�"I ctuapemalion l sumntticarticnnd Policy number art:
Ca �auL G P ,as 9—0 D�✓i�
CERTIFICATEOFEKEMPr10 MWORKERS'
COMPENSATION SURANCE
(This scrum.need not uncompleted if rhe permit is rmmm Wndmd dollars(SIM) -
orleea)
I certify that in the performance of the work for which Nis permit Is issued.1 shall not
employ any person in any manner so u to become subject to the Workeri Compensation
Law,of California.Date
Applicant
NOTICE TO APPLICANT:IL after making ibis Ceni Ecom or Exemption,you ahold
Immune subject in the Worker's Compensation provisions of the Labor Code,you must
.JO fonhwith comply with such provisions or this permit shall W deemed revoked.
Z Fr CONSTRUCTION LENDING AGENCY
F r Ihereby affirm Nm there is a construction lending agency per the performance of _
Cali .moi
be work for which this permit is issued(Sec.3091.Civ.C.)
Wti Q Leader'.Name
Z) z lender's Address
U Q I certify that I have read His application and sum that the a Wve information is
Ion H cancel.1 agree to comply with all city and county ordinances and sum laws relating to
O V building construction,and hereby authorin representatives of this city to enter upon the /�! �I,',/7ryr(/, //�//
LU ahovmmendonm property for inspected pa pmposea (/`'_!/KJN/ l
a (We)agree to Ove,indemnify and keep harmless the City of Cupertino against
h liabilities,judgments,costs and expenses which may in any way accrue against said City
O z APPLICANTeUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
tCodc.
OU REGU�.ATIONS. J 3
Re-roofs
I mumof Applicant/ mounter ate -
H ZARDOUS MATERIALS DISCLOSURE Type Of ROOF'
Will the applicant or future building occupant arum or handle havamuus material
defined by one Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Suction 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
QYn4 ANu
-Will the applicant or furan building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hanniom airconmminents m dcGned by the Bay Arca Air Quality Management all new materials for inspection.
trio?
❑Yes 4No
1 have mad the hmatmnus materials cquircments under Chapter 6.95 of the Califon
ria Health At Safety Cade.Sectors,25505,25533 and 25534.1 undeasmad Ihm if the Wilding
does not cuam ily have a mnml.Nat it is my responsibility m and ly olm aeupanl of be
re mcnts its max be met priortu; aanccrficcnlmid, rOccuaney. - Signature of Applicant _ Date -
wren ar anmoniee em - All roof coverings to be Class"B" or better