08020105CITY OF CUPERTINO
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BUILDING DIVISION PEI0I'
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Bu1LD�NBMESISTONYDALE DR
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AKEENA SOLAR, INC
P08020105
OWNER'
. CONTROL NO.
(408)867-0558
ARCHITECT/ENGINEER:
BURRING PERMIT INFO
BL.DG ELECT PLUMB MECH
LICENSED CONTRAMMT S DECLARATION
Chapter
Job Description
I hereby affirm that I am licensed under provisions of 9 (commencing
with Section 7000) of'Division 3 of the Business and Professions Code. anil my lic-em is
INSTALL 18 ROOF MOUNTED PV SOLAR MODULES —PAINT
Da full rorand etAxt.�
License Cl
PANEL FRAMING TO MATCH ROOF COLOR
Date DmraaOf
C.
A CHn=S DECLAR40ION
1 understand my plans shall he used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
.
1 hereby atirm that 1 am exempt from Ilse Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construe. alter, improve, demolish, or mpa'rr any smictum
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 Elie Contractors License Lw (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$ 2 0 0 0 0
that he is exempt therefrom and the basis for the alleged exemption. Any violatfon of
3 2 6 3 7 0 2 0 `. ` b Number
Occupancy
Perne y Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mom than rive hundred dollars (SYM
❑ L as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Ptofessons Coda: The Contractors License Law ears not apply to an owner of
property who builds or improves thereon, and who does such wort himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvanerr is sold within one year of complexion, the owner -
builder will have the burden of proving that he did not h did or Improve for purpose of
sale).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct that project (Sec. 7044, Business and Professions Code:) The Contractors U-
ccum Law does not apply to an owner of property who builds or improves thereon, and ,
who contracts for such projects with a contractor(s) licensed pursuant to the Comractors
License Law.
❑ 1 am exempt under Sec , B At P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Cmificam of Consent to self -insure for Wori¢rs CDmpen-
sadon, as provided for by Section 3700 of the Labor Code, for the performance of the
worn for which this permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
37W of the Labor Code, for the performance of the work for which this permit is issued
My Workers Cam pe cation Insurance carrier and Policy number are:
Carrier: SJM-ke F,,n� d Policy No_: / 3--80 C
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
Milli season need not be completed if tie permit is for one hundred dollars ($100)
or IcsL )
1 certify that in ilia 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. Dam
Applicant
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should
beconna subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONYMUCTION LENDING AGENCY
I hereby &film that there Is a conAmcdon landing agency for the performance of
the wort for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lenders Address
1 certify that 1 have read this application and state that the above information is
cotmcL 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 color upon the
above -mentioned property for inspection purposes
(We) agree to save, indemnify aid keep hamiless that City of Cupertino against
liabilities, judgmcns, costs and expenses which may In any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: —� "�2C
SOURCE ggEG()LATIONS.
Re -roofs ��
Type of Roof
� `
il.4,Al i/1144--) ��Y►/fAAA - 1yf�S
Sn fAppliant/Contr r !4
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building O=q=t store of handle hazardous malarial
as defined by the Cupcitmo Municipal Code. Chapter 9.12. and the Health and Safety
Code, Section 25s3ua)a �
All roofs shall be inspected to any roofing material being installed.
prior
If a roof is installed without first obtaining an inspection,agree to remove
Will the applicant or future building occupant use equipment or devices which
.I
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
Distria7
❑Yes No
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health k Sitkiy Cade, Sections 25503, 25533 and 25534.1 understand that if the building
does not currently have a tenant. that it is my responsibility to notify the occupant of the
requirements which must be met prior to issuance or ■a ofOccupancy.
Signature of Applicant Date
�Certificate
,tom:a tn/ � �� ` 1`=
g Class All roof coverings to be Cl" or better
Date e '
t
Owner thor'vrA agentent