BLD-2019-0653_SignedPermit.pdfBUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 1121 ROLLINGDELL CT Cupertino
APN: 359 34 009
PERMIT NO: BLD-2019-0653
OWNER'S NAME: JAYACHANDRAN JAY AND GEETHA
OWNER'S PHONE: Not Provided
CONTRACTOR:
CLEAN SOLAR INC, 1445 KOLL CIRCLE SUITE 109 SAN JOSE
CONTRACTOR PHONE:
4085296168
DATE ISSUED 8/8/2019 2:54:15 PM
ISSUED BY: KDUNBAR
VALUATION: $21867
JOB DESCRIPTION
SYSTEM (5.48 KW)
(N) 15-PANEL ROOF MOUNTED PV
LICENSED CONTRACTOR DECLARATION
9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full
CONTRACTOR:
CLEAN
LICENSED
C10
LICENSED
910849
EXP
02/29/2020
I hereby
force
I hereby
SOLAR INC
CLASS:
ELECTRICAL, C46 SOLAR
NO:
DATE:
affirm that I am licensed
and effect.
affirm under penatiy of
I have and will maintain a
for which this permit is issued.
I have and will maintain Worker's
I certify that in the performance
laws of California.
with such provisions or this
under the provisions of Chapter
perjury one of the following three
certificate of consent to self -insure
Compensation Insurance,
of the work for which this
If, after making this certificate
permit shall be deemed revoked.
declarations:
for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the
work
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's
of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith
V
issued.
Compensation
comply
HAZARDOUS MATERIALS DISCLOSURE
Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance
I have read the hazardous materials requirements under
the Cupertino Municipal Code, Chapter 9.12 and the Health
V
with
equipment
Municipal
& Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use
as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino
Sections 25505, 25533, and 25534.
for this project.
Firm Certification No:
or devices which emit hazardous air contaminants
Code, Chapter 9.12 and the Health & Safety Code,
An EPA Lead -Safe Certified Renovator will be responsible
Firm Name:
No EPA Lead -Safe Certified Firm is required for this project.
Certified
CONSTRUCTION LENDING AGENCY
lending agency for the performance of the work which this permit is issued (Section 3097, Civil Code).
Lender's Address:
I hereby
Yes
affirm
under penalty of perjury that there is a construction
No
V
Lender's
Name:
APPLICATION CERTIFICATION
and state that the above
representatives of this city
liabilities, judgements, costs,
will comply with all non -point source
PC
information is correct. I agree to comply with all city and county ordinances and state laws relating to building
to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep
and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,
regulations per the Cupertino Municipal Code, Section 9.18.
I certify that I have read this application
construction, and hereby authorize
harmless the City of Cupertino against
the applicant understands and
Signature:
(
—
Every permit issued shall become invalid unless the work on the site authorized by such permit is commenced within 365 days after its issuance, or if the work authorized on the site by such permit is suspended or abandoned for a period
of 365 days after the time the work is commenced.