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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO.
1179 STAFFORD DR PETERSEN—D AN INC 0cm-,ni 49
OWNER'S NAME: PERMrr ISSUE DATE
PHO A CONTROL NO.
510) 494-9982
ARCHTIEC(ENGINEER: BUILDING PERMIT iNFo
BLDG ELECT PLUMB MECH
0 0 0 0
a O O LICENSED CONTRACTOR'S DECLARATION
m P I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
Z with Section 71100)of Division 3 or the Business and Prof s C de,and my licensee
'Mm in full force andeffecL LL RF MOUNTD PHOTOVOLTAIC. SYS, RESIDENTIAL
ta Z License asCA09.c.M 91
3,p Date Contractor
ARCHITECTS DEC I N
U I understand my plans shall be used as public records
a
U.
H Licensed Professional
OWNER-BUILDER DECLARATION
a I hereby alTrrm that I am exempt from the Contractor's License Law for the
Q O following reason.(Section 7031.5,Business and Professions Code:Any city or county
,e m which requires a permit to construct.after,improve,demolish,or repair any structure
y Z r prior kr its issuance,also requires the applicant for such permit to file a signed statement
_< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
t—$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of SU000
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5500). P Y YP
❑1,as owner of the property,or my employees with wages as their sale compensation, 36211023 . 0 0
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 Required Inspections
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.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Cade:)The Contractors Li-
ccum Law docs not apply to an owner of property who builds or improves thereon,and
who contracts forsuch projects with a contractor(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
I hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure for Workees Compen-
sation,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 Workefs Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued
My Workels�C//99//ppnnpensation insure carrier and Policy number are: 75—/Carrier—/W
` /t
Carrier. -/-CLC (�>Lt � Policy No.: -7 ✓�`T I
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Chris section need not be completed if the permit is for one hundred dollars($100)
or less)
I cetify 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 Workers'Compensation
Taws 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 the Labor Code,you must
O forthwith comply with such provisions or this permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
�i> the work fur which this permit is issued(Sec.3097,Civ.C.)
OWa Q Lender's Name
Z L.cnder's Address
U 0 1 certify that I have read this application and state that the above information is
Ly" cortccL I agree to comply with all city and county ordinances and state laws relating to
0 V building concoction,and hereby authorise representatives of this city to enter upon the
above-mentioned property for inpe 'on purposes
H a (We)agree io save,indcm.y and keep harmless the City of Cupertino against
h.y to liabilities,judgmedts,costs and ex nses which may in anyway accrue against said City
U z in consequencea the granting o is permit.
APPLICA U DERSTA AND WILL COMPLY WITH ALL ION-PINT Issued by: Date j CEJ
SOURCE G TIONS.
Da
Re-roofs
signnre nr p icani/Con r
H OUS MA LS
DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazudous material
as defined by the Cupertino Municipal Code,Cbapter 9.12,and the Health and Safety
Code,Section 25532(a)?
❑reNo All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District] all new materials for inspection.
❑Yes ONo
1 have the hazard materials requirements under Chapter 6.95 of the Califor.
nia Health&S etyCode,Se 25505,25533 and 25534.1 understand Nat if the building
does not c fly have a that it is my responsibility to notify the occupant of the
reyuiremc hick must )th l rior to issuance of a Ccrtificatc of cup ry. Signature of Applicant Date
Owner or a orized agcn Date
All roof coverings to be Class'J�`'or better
CITY OF CUPERTINO
SOLAR PANEL
CUPEkTINO PERMIT APPLICATION FORM
APN# o o Date:
Building Address:
Owner's Name: SA� �,ap ��2� ^n 4N i ti�/ Phone#:
Z/09
Contractor: Phone#: 57 U_qq 1l s g98Z Contractor License#:
�Grt S
D.CAI / Fax #: p _ — P 1v
Contact: „ /�� , // Phone#: �/0—C9tl_?7vq Cup%in®us�iness License#:
A A/6 Fax#: �>
Number of Panels/Units: y10 ,. y�-r) Kilowatts (Commercial Only):
Job Description: Aa)F-- .44 0UIIJ TED 't_,JfVT pVv(__rA16 c'c STF /( AV51bF,., ITT4L
Project Size: Express ❑ Standard X Large ❑ Major❑
Residential Commercial ❑ Valuation (cost of project)
C v�d
Green Points:
1.2 KW—6 Points ❑ 2.4 KW— 12 Points 3.6 KW— 18 Points ❑
Quantity Fee ID Fee Description Fee Permit Type
Group
1 SOLARPANL Commercial Solar Panel E SOLAR-COMM
1PHOTOVCOM Photovoltaic System E
Commercial
1 PHOTOQP Photovoltaic Quasi E SOLAR-QUASI
Public
1BSEISMICO Seismic Commercial E
1 ELCPLNCK Plan Check Fee E
1BCBSC Cal Bldg Standards B ALL PERMIT TYPES
Commission Fee COMM & RESID
1 SOLARRES Residential Solar Panel E SOLAR-RES
Revised 01/07/09
Community Development
10300 Torre Avenue
sli
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
CUPER:11NO
Building Ike artment
JOB ADDRESS: I 5TAF19-04P 09 PERMIT #
OWNER'S NAME: .SA S r.r8�t/�'1�4 An/ PHONE # ./0 -51-/f— 2
GENERAL CONTRACTOR: ,Q FAX # w
I am not using any subcontractors: .;20,10-7
ign e Da e
Please check applicable,subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring:Carpeting
Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date