10030003 CITY OF CUPERTINO BUILDING PERMIT
BI'TLDING ADDRESS: 18731 TILSON AVE CONTRACTOR:COBALT POWER PERMIT NO: 10030003
SYSTEMS,INC
G.,_,AR'S NAME: PHILIP&NANCY BOYLE
885 MAUDE AVE DATE ISSUED:03/10/2010
MOUNTAIN VIEW,CA 94043 PHONE NO:(650)938-9574
OWNER'S PHONE: 4087421580
9 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG� ELECT� PLUMB r
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License Class Lic.# MECH r— RESIDENTIAL COMMERCIAL
Contractor(1MV Lt T �( � gate JOB DESCRIPTION: INSTALL ROOF MOUNTED PHOTOVOLTAIC SYSTEM
I hereby affirm that I am licensed under the provisions of Chapter 9 W[NO
(commencing with Section 7000)of Division 3 of the Business&Professions BATTERY BACK-UP 24#PANELS/UNITS
Code and that my license is in full force and effect.
I 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.
I have and will maintain Worker's Compensation Insurance,as provided for by Valuation:$33316
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area:
permit is issued.
APPLICANT CERTIFICATION APN Number:37518049.00 Occupancy Type:
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 PENT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all no - oint source re lations per the Cupertino Municipal Code,Section
9.1 R Issued by: Date: �
__ II� , �, �
S.__ .ire Date
❑ NER-BUILDER DECLARATION RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044, Date:
Business&Professions Code) Signature of Applicant:
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's
I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code ections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I Ow er ora ori agent:
become subject to the Worker's Compensation provisions of the Labor Code,I must Date:
.3 v
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
co-- -t.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
t ling construction,and hereby authorize representatives of this city to enter Lender's Name
ur. she above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this er t.Addition y,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non- -int urce regul ns per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Signature 2� Date U v Licensed Professional
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