11100003 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21580 FITZGERALD DR CONTRACTOR:PETERISEN-DEAN INC PERMIT NO: 1 1 100003
OWNER'S NAME: MARK&DANETTTE MAVROUDIS 7980 ENTERPRISE DR DATE ISSUED: 10/18/2011
nWNER'S PHONE: 408361 1582 NEWARK,CA 94560
PHONE NO:(510)494-9982
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL,0 COMMF,RCIAL11
License Class (L y1< L.ic.# }/r,g /( -f- / INSTALL ROOF MOUNTED PV SYSTEM 18 PANELS 3.7 KW
Contractor Date
hereby aft m that 1 am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$17000
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. APN Number:32647009.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I 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 WITHI" PERMIT ISSUANCE OR
upon the above mentioned property for inspection purposes. (We)agree to save 180 DA ROM LAST CALLED INSPECTI N.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the '— '---� Jb
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: `
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
.Signature Date RE-ROOFS:
All roots 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
r-
OWNER-BUILDER DECLARATION inspection.
I ucreby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant_ Date:
the following two reasons:
1,as owner of the property,or my employees with wages as their sole compensation, ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should 1 store or handle hazardous
1 have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District 1
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,2.5533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Owner or authorized agent: Date: �l
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 Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have read this application and state that the above information is
correct. I 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, ARCHITECT'S DECLARATION
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall!ne used as public records.
gr- 'rig of this permit.Additionally,the applicant understands and will comply
1 non-point source regulations per the Cupertino Municipal Code.Section t_.ieensad Professional
Signature Date