06050153 /
CITY OF CUPERTINO
BUILDING DIVISION PERMIT hCU .jTI2AG5TOR I I1VP'ORMATQ
BUILDING ADDRESS: REGRID POWER PFRmfrND'06050153
11425 CHAPSAN LN
R'S NAME: PERMIT ISSUE DATE
DORAN DRUSINSKY 1624 DELL
/ PH NE: SANITARY NO. CONTROL NO.
(408) 927-0811
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
ioo LICENSED CONTRACTOR'S DECLARATION Job DescriptioniZ I hreb
ey affiam ns rm fast 1 licensed under provisioof Chapter 9(commencing
a< with Section 70M)of Division l of the BLWns and Profession,Codo,ad my license Isas
ml0fmdgvd SOLAR ELECTRIC SYS7 KTRESID ]100
j q i License Clue Lie.• C7 If {.'
iP, Dau Conunctor
ggg ARCHITECT-S DECLARA ON CCC����
1 I understand my p! Nall be used u public recomb
�`7� Licensed Prefessunsl
AM
OWNER-BUILDER DECLARATION
2 i M I hereby afire that 1 am.cmpt from the Contractors License Law far the yt+
a o following region.(Section 7031.5,Business and Profusions Cade:My city m county F1 2 2 216
C.
9 which requires a Permit to construct,alter.improve.demolW,m repair any suuctum A.r
?ice prior in its isawnec,Win requires the applicant parsuch permit to Bk a signed satomenla,/Area eU �J�Yaluation
Sq
pp o umtheianeensedpwtaanttaumprovisianaaftheContmewrsuecnstLaw(Chaptm9 .Ft. Floor
t�B (commencing with Section 7000)of Division]of the Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged gumption.Any violation of
Section 7071.7 by any applicant for a permit subjects the applicant to a civil Penalty of K996FrUU_ Occupancy Type
net mom than Big hundred doll.($500). -
Q 1,as owner of the property,or my employees with wages as theuam compensation,
will de the work,and the mructom is motimended oranered fo.ae(Sec.70a,Business Required Inspections
and Profession Code:The Contractors Licwe Law dors ret apply to e ns an own"of q P
property who builds orlmprognat .eM whodoessuchwark hinsufor through bis
Own employe.,provided unused improwmenu me not intended orolfered forage.If. '
however,the building or improvement is aid within one yea of emgpution,the owner-
builder MB haw the burdco of proving that he did not build or Improve far purpose of
ale.).
Q 1.as owuer of the property,s.odusively contraming with Reasoned cmtiractora m
construct the peke(See.7044.Business and Proposing.Code:)The Contractor's Li-
ansa Law does not apply to an comer aproperty who builds or Improves dtemmn.and.
who contracts for such projects with a contracums)Sato pea nam to mcs Contractor's '
Lone g"Law.
Q l are exempt under See ,B k P C for this=00
Dau
aj IN,
WORKER'S COMPENSATION DECLARATION
1 thereby affirm under pe.lty of perjury aro of the following declarWons:
❑I haw and will maintain aCortlRauaf Conant w elf-insum for Wort e,Compen-
sation,as provided for by Section 7700 of the Labor Code,for the performarme of We
work f which this Ismail is Iowa
I haw and will maintain Workers Compensation Insurance,as required by Schon
3700 of the Labor Code,for tie performauee of the wick for which this permit is WOOL
My WorW'Cemism nl.urante 'er and Policy number art:
Carr. Policy No.:
CERTIFICATE OF EJ PITON FROM WORKERS'
COMPENSATION INSURANCE
mus sermon teed not be conmple"lithe permit Is foram,hundrW doll.($100)
or less)
1 ttnify that In the performance of the wart for which this permit Is issued,I shall ret
employ any person in any manners an W become abject to tie WmkeraCompenation
Laws of CellImia.Data
Appliant
NOTICE TO APPLICANT:IL after making this CeniRam of Eamption,yen should
become ago"t to the Worker's Compensation provisions of tits Labor Code,yen most
.JO forthwith comply with such provisions Or this permit Nall be domed mwk,d.
CONSIRUCrION LENDING AGENCY
[-+ 1hamhy ailing that dam Is.dnawcdnn lending agency for data,perrmeana of
r1,ti the work for which Ws Permit Is Issued(Sec.3097.Cih,C.)
A lenders Name
]z Landers Address
U0 I Cattily dust I haw read this application and sate mal the show,information is
IL F Comm I agree to comply with all city and county ordinances and rote laws muting to
OU building construction,and hereby authmine repratenutiws of this city to enter upon fact
W ahow-mentioned pmperty,for inspection putpnms
(We)rime maw,indemnify and top harmless tie City of Cupertino games
ti w liabilities judgmenu.costs and cape..which may many way accrue against said City
U 2 in consequence,of than granting of this Permit. /
a..i APP UN RSTANDS AND WILL COMPLY WITH LL N -POINT Issued by: Date
SO R UL f s.
1 k•G 11 AA �/!7 0& Re-roofs
Signature of ApplicadComos for Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant m future building eccupon mums or handle haardous material
as dented by the Cupertino Municipal Code.Chapter 9.12.and tits Health and Safety
Section 255ax(a)7 All roofs shall be inspected prior to any roofing material being installed.
QY.the tMo
Will Applicant uwm
building oavpont um equipment or derlos which If a roof is installed without first obtaining an inspection,I agree to remove
emit havrdmus air conumi.nU a lathed by Irk Bay Am.Air Quality Management all new materials for inspection.
District?
QY. XNo
I have mal ft has ntamrials requirements;under Chap=6.95Mthe Califor-
nig Health&Safety Cunt.Sections 25X0.25577 arW 75534.1 understand esu ifthe Wiling -
da.Iwt sly haw a t.that it u my mrponslMli to ratify the r."
of Nc
require n q�mymbe t`�e�rmiagane,ar,cenirte.mar�a ,r Signature of Applicant Date
All roof coverings to be Class'B"or better
Owners amhariad agent. ) t