09070112CY OF CUPERIINU
BUILDING DIVISION PERMIT
BUILDING ADDR
10585
OWNER'S NAME:
ARCHITECTIENGINEER:
I a o LICENSED CON'TRACTOR'S DECLARATION
ulUI hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7008) of Division 3 of the Business and Professions Code, and my license is
H in full force and gIfgc�.,,
D t2 z License Class C'-`'�"� GAO Lic• g
n
4;:,m Date =�(jC>A Contractor
„u ARCHITECTS DECLARATION
g � U 1 understand my plans shall be used as public records
o,
Z G y Licensed Professional
n y OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
LOO following reason. (Section 7031.5, Business and Professions Code: Any city or county
.4. � which requires a permit to construct, alter, improve, demolish, or repair any structure
n Z y prior to its issuance, also requires the applicant for such permit to file a signed statement
_ that he is licensed pursuant to the previsions of the Contractor's License Law (Chapter 9
n t•- (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
x. .. 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)_
❑ 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
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 sale. If,
however, the building or improvement is sold within one year of compledon, the owner -
builder will have the burden of proving that he did not build at improve for purpose of
sale.).
❑ 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.
cense Law does not apply to an owner of property who Wilds or improves thereon, and
who contracts for such projects with a cantractor(s) licensed pursuant to the Contractor's
License Law.
❑ 1 am exempt under Sec , B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 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
wort for which this permit is issued.
ISI I have and will maintain Worker's Compensation Insurance, as required by Section
700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier1 and Policy number am: �
Carier7c E A(Jq?712 6e[C�rtlPol)cyNo.:1kZ3 6734 6 s 7i
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manner so as to become subject to the Workers' Compensation
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 Ne tabor Code, you must
.J O forthwith comply with such provisions or this permit shall be deemed revoked.
z , CONSTRUCTION LENDING AGENCY
[-+ 4 1 hereby affirm that there is a construction lending agency for the performance of
ix > the work for which this permit is issued (Sec. 3097, Civ. C.)
a" Lender's Name
r7 z Lender's Address
U Q 1 certify that 1 have read this application and state that the above information is
LL correct. 1 agree to comply with all city and county ordinances and state laws relating to
0 U building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
H a (We) agree to save, indemnify and keep harmless the City of Cupertino against
r.y to liabilitirs,judgmcros, costs and expenses which may in any way acerae against said City
U 'Z in consequence of the granting of this permit.
^+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE R ULATIONS.
Signature of Applirant/Contraclor te
HAZARDOUS MATERIALS DISCLOSURE
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
Code, Section 25532(a)?
❑ Yes 0"'No
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
District?
❑ Yes A?(u
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health &Safety Code, Sections 25505,25533 and 25534.lunderstand that ifthe building
does not curcn0y have a tenant. that it is my responsibility to notify the occupant of the
requirem nis which must be met riot to issuance of a Certificate of Occup'
Owner or authorized agent Uatc
0) 638-1028
Job Description
ROOF RACK MOUNT PHOTOVOLTAIC SYSTEM
Sq. Ft.
Valuation
APN Number Occupancy Type
32608028.00
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date _?_ 2-/
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant
Date
All roof coverings to be Class 'n" or better
PGRMff NO.
PERMIT ISSUE DATE
PE 148
A
2889
CONTROL NO.
BUILDING PERMrrINFO
BLDG
ELECT
PLUMB MECH
Job Description
ROOF RACK MOUNT PHOTOVOLTAIC SYSTEM
Sq. Ft.
Valuation
APN Number Occupancy Type
32608028.00
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date _?_ 2-/
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant
Date
All roof coverings to be Class 'n" or better