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BUILDING DIVISION
)ING ADDRESS:
`TEA'S NAME:
ARCHITECT/ENGINEER:
PERMIT
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
n full force and eft Lic. R�
I Class Contractor
Date
ARCHITECTS DECLARATION
I undcruand my plans shall be used as public records
Licensed prufcssional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's Liccnsc Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any sluctum
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Conttacwr's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
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 penalty of
not more than five hundred dollars (5500).
0 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
and Professions Code: The Contractors 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 sale. 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 conuumrs to
construct the project (Sec. 7044, Business and Professions Code:) The Conoutoes Li-
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractors) licensed pursuant to the Contractors
License Law. B R P C for this reason
0 1 am exempt under Sec.
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Job Description
INSTALL :ROOF MOUNTED PHOTOVOLTAIC SYS (NO BATTERY
BACKUP)
q. Ft. Floor Area
umber
3162804?.00
Date
9W
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 workers Compen-
tion, as provided for by Section 3700 of the Labor Code. for the performance of the
mrk for which this permit is issued.
] I have and will maintain Workers Compensation Insurance, as required by Section
f00 of the Labor Code. for the performance of the work for which this permit is issued•
ly Workers
Compensation Insuni d Policy lnumber r/arc:
artiera _ �anlcy No.:/CEtT1FICATE OF EXEM�ON ORKERt�S'
COMPENSATION INSURANCE
I
(•this section need not be completed if the permit is for one hundred dollars ($100)
r less.)
certify that in the performance of the work for which this permit is issued. I shall not
mploy any person in any manner so as to become subject to the Workers' Compensation
aws of California. Date
kppficant
40T10E TO APPLICANT: If, after making this Certificate of Exemption, you should
ecome subject to the Worker's Compensation provisions of the Labor Code, you must
'orthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
L.endces Name
Lenders Address
I certify that I have read this application and state that the above information is
correct. l agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
I
co uence of the granting of this permit.
APP ICA UNDE NDS AND WILL COMPLY WITH A L NO
S CE REGU v
ignature of u ontractor 7 ate
HAZARDOUS MATERIALS DISCLOSURE
Will tie applicant
future
MunicipalCoding e Chapter 9.12, andhandle
ihc Hca�llltous material
and Safety
as defined by the Cupertino
,de,Scction 25532(a)? j
❑Yes o
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants u dcfu by the Bay Area Air Quality Management
District?
0 Yes u
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health &Safety Code, Sections 505, 25533 and 25534. I understand that if the building
does not c rrendy have a tenan t it is my responsibility to notithe occupant of the
_..... y�.� ,..ht, -h nnusHbc or to issuance of a Certificate t OcCyp �y
Date
Issued b r
Re -roof:
Type of Roof
Required Inspections
All roof 3 shall be inspected prior to any
If a roof is installed without first obtaini
all new materials for inspection.
S'atu -e of Applicant
Date G�- 7v D
al being installed.
ioI, I agree to re
Date
Igo ..
All roof coverings to be Class 'A" or better