08010001 CITY OF CUPERTINO • -r farK ash ' a i .�'� �
BUILDING DIVISION
PERMIT 34
a. &.+'.,.'';x ' ._
BUILDING ADDRESS: PERMIT NO.
10727 RANDY LN COBALT POWER SYSTEMS, INC 08010001
OWNER'S NAME: PERMIT LSUE DATE
GRIFFIN TERRY L AND MARGARET 2444 OLD MIDDLEFIELD WAY 01/09/2008
NO: oma o SANITARY NO. CONTROL NO.
(650) 938-9574
ARCHTTEC(ENGINEER: BUTMINO MRM7INFO
BLDG ELECTPLUMB MECH
O O E l�
o O LICENSED CONTRACTOR'S DECLARATION - Job Description
1 thereby N
eby affirm 1 am(ken ed under provisions of Chapter 9(commencing - p
with Section 70 )ofDiviaonlofdecBu®neAnandProfcuouCode,antlmylicenseb ROOF MOUNTED PHOTOVOLTAIC SYSTEM(NO BATTRY BKUP)
a in full farce and eRe -2O
Z License Cl As J _) Lm.g
Dam Contractor
ARCHITECT'S DECLA
1 Analogized my plans shall be used u public recur
7y
C�n Licenced Professional
3 OWNER-BUILDER DECLARATION
f 1 Mrohy.(Sero that 11. exempt from dee cWtow O License law for 0e
110!O O fallowing reaann.(Section RD13,Business and Pm.dem a Cade:Any city as caumy
which rege inga o permt re construct.do alien improve,demolish,or repair any ewclure -
Z� priormitsiuuamp,dso requires tui applicant far anchPermit mccam ga (Chaps cot
4Q that he is licensed pursuant as dee provisions of do Contractor's lJceme law(Chaprer9 Sq.Ft.Floor Area Valuation
B (commend.&with SenlenWXI])of Division 3 of de Bussomom!Profusi...Code)or $21037
.. that he Is exempt themfmm and the basis for the Alleged eamption.Any violation of
Section 7031.5 by any applicant for•permit anbjats de applicant an ALM)penalty of N Number Occas anC e
not mom Nan five hundmd dollars(SM. 31602041�0' p y�p
❑1,As owner of fee property,or my employ=with mpg u deb selecompensation,
Mlido the work and the swmum u natimmnded oroRered farsale(Sac.70 .Busimas
and Pmfeum
ians Code:The Commor's Liam Law does not apply m an owner of Required Inspections
property who builds or i mprovas uwcon,and who doessuch work himself or through his
ownemployces,provided that such improvements are not intended aro@rod forsale.If.
however,the Wilding or improvement Is gold within am yew of completion,dee owner.
builder will have the burdan of prevmg that he did not build or improve for purpose of
tile.).
❑i,As owner of the property,am exclusively contacting wide licensed contractors or
construct the pmjem(Sec.7044,Business and Professions Code:)The Connector's Li-
ceme law duan not apply to an owner of property who Wilds or improvm demon,and,
who contracts for such pmjeets with a contracmr(O licensed pursuant An the Contractor's
License Law.
❑lameaemptundw See ,B&PCforthis..
Owner Data
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury am of the following declarations:
Ihaveandwillmainuina C.r rl.nsofConsentmself-lnsumforWorker'sCommn-
sedan.an provided for by Section 3700 of the labor Code,fm the performance of dee
gor which this permh is issued.
f
ave and will maintain Workers Commnsation Insurance,an required by section
3700ofthe labor Code,for the performance of the work for which this permit is issued. '
My Warkm'a Cmnammand Ing, cart.-and Policy number art:
Grier. ,�L'L"/G�1/7 //Vi7�1 PoIicY Na.:G�7/rD/lDA�7� .
CERTIFICATE EKk ON FROM WORKERS'
COMPENSATION INSURANCE
(Thu action mod rot f e completed if the permit is far me hundmd dollen(s l W)
M las.)
1 certify that in the performance of the work for which this permit is issued.I aha0 not
employ any permni"arty roamer an An in income subject to dee Warkm Compensation
laws of Caliromla.Date
Applicant
NOTICE TO APPLICANT:If,aMr making this Cer iftam of Exemption,you should
become subject In the Worker's Cmnpensition provisions of the labor Code,you must
.J 0 forthwith comply with such Provisions or this permit shall W domed eveked.
'Z
ti 51 CONSTRUCTION LENDING AGENCY
F IWmhy is a lending agnnry for the perfumtuec of
pi the wash for which Oda permit is usuctl(Sec J097,Civ.C.)
GQ Lender's Name
Z:)z lender's Address
U Q 1 certify that I have mad this application and suns that the above information is
lyF corms T agree to comply with all city and county aNlnsnces and cum laws miming m
C)C) Wilding convection,and hereby audmive repcco mtime of this city an enter,upon the
W abave-mcnuanctl Property fand.1mtiom whilums
y (We)agree to Ana,indemnify and keep hamdess the City of Cupertino ageimt
s.a y li.bilin
of theeoatsantlof this ceonit. may in Anyway acme gain0said City
()7 in PLICA T of deeRSTAN of this pe WILL
rte• APPLICANT UNDERSTANDS AN WILL COMPLY WITH ALL NON-POINT Issued by: Date d�
SOURCE 0.EC TIONS.
9 3
W Re-roofs
Rt
turn o pp ✓cors ter Dam
/ HAZ DOUR MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building atapantnom ar handle heuMous material -
as doMcd by the Cupertino Municipal Code,Chapter 9.12 and the Heald and Safety
Code,See Y.n. 'O�No iss3z(a)? All roofs shall be inspected prior to any roofing material being installed.
Y.
OWill the applicant orfuturebuilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,.I agree to remove
IL haurdous air contaminants As defined by the Bay Area Air Quality Management all new materials for inspection.
D'aticl?
❑Ym pplu
I have mW the tomatoes memorials requirements under Chapter 6.95 of the Califoo
ria Haid&SafmyCade Seen.W05,25533 and 25534.1 understand that ifthe Wilding
does at cortenlly Wm a aught,that it as my asibilty m notify de mcupant or de
mgcim cat wh'hm at prior rot chifiame of Occupancy.
�O Signature of Applicant Date
ow r.rauthorizad rot D,m All roof coverings to be Class"B"or better