04030224 CITY OF CUPERTINO °+'
BUILDING DIVISION PCRMIT
C0N1RAGTMINF0RMATIQN
ff.'&I�I
BUILDING ADDRESS: MC SOLAR ENGINEERING PERMIT N'04030224
1VD
ER'S NAME: PERMIT ISSUE DATE
t ST. JOSEPH S
PHONE: SANITARY NO. CONTROL NO.
(408) 261-1213
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
eC0 LICENSED CONTRACTOR'S DECLARATION Job Description
w 1 hereby art that I am lianed under revisions of Chapter 9(Commencing
i� wire SectionlmB)aroiviaiOn3orthc easinua �a ProfessiOm Crdn.andmyfanscls
^3� in full Come and Off i165 PHOTOVOLTAIC SYSTEM .ON ROOF
License Cl Lig
41-0 Date AH HI�'mcrs-DkCLAR 1 N �70 ItVA�
�a 1undcrsla A y plans shall Ire used m� crow
0-u
GLicensed Professional
3
iOWNER-BUILDER DECLARATION
if I hereby al'frre that I am exempt from the Contractors License Law for LW
_O O rollowing reason.(Section 701.5.Business and PmRssium Cade:Any city,or County
which requires a permit m construct.alien impmve.i llah,Or repair any structon,
FI< pdonu its issuance.also tcquires the applicant for such permit to rile a signed statement
s that lar,6 licensed pursuant to the prevision of tM Contractor's liana Law(Chapter 9 Sq. Ft. Floor Area V#2t�a 000
rc�$ (commencing with Section 7000)of Division 3 or the Business and Proreenums Codc)or
.. that he is attempt thcrcfrom end the basis for the alleged cttempdon.Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant 10 ACIVl penalty Of APN Number Occupancy Type
not mom then rK hundred dollars(gs00). 31626093 . 00
❑1,a owner Of the ptopcny,or my employees with wages as their aole Compensation, teral 09,
.sill do the work,and the structure u not intended or offered per...(S.C.70ae,Business
and proprietors Code:The Contractors License law don not apply 0 in owner of Required Inspections
properly who builds or improves thereon,and who docs such work hi fusel f or through his
own employees,provided that such imprevemeno art not intended oroffered forsale.If.
huilder thebuildingor den or pmatussoldwithinore year .of Completion.the use of j
builder will have the burden improvement
ement i that he did not Wild or improse for purpose of
sal.). 7
❑1,m owner of do property,am exclusively convening wish harmed Contractors to 3/
construct she project(Sec.1064,Bulinus end Profusions Code:)The Conmetori Li.
c me law does not apply to an owner of property who Wilds or improves thereon,and
who contracts for such pmjects with a cormo cmr(s)liarseed pursuant on she Contractors
License law.
I am exempaondo,Sec. .B A P C for this moon
Date
WORKER'S COMPENSATION DECLARATION
1 lereby affirm under Penalty of perjury one of the following declamation:
1 ham and will mainum aCcrufcau of Covent to sclGinsum for Workers Comped.
sation,an provided for by Section 37W of the labor Code,for the performance of the
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the labor Code,for she Performance of the work for which t, omit is issued.
My Workers ComPcnation Insurance artier and Policy number am-
Cartier.ad S ',l r;C r LIN8Policy NO.: C./ —0,V
CERTIFICATE OF EXEMPTION FROM KERS'
COMPENSATION INSURANCE
Crea section need not be compacted if the pmmit is forone hundrod dollars(SIM)
or ices.
1 anify that in the performance of de work for which this Permit is issued.I shall not
employ any person in any manner so as to bocomC subject to the Workers Compensation
Laws of California.Dau
AppltCenl
NOTICE TO APPLICANT:Ir,after making this Certificate of Exemption,you should
become subject m the Worker'a Compensation previsions of the labor CoCIC,you must
.�Z forthwith comply will such prevision in this permit shall W decreed revoked.
ZO CONSTRUCTION LENDING AGENCY
[r (hereby affirm that thea is a cnmuwctirn lending agency for the performance or
lY> she work for which Nis permit u issued(Sec.3097.Ci,C.)
W0. A Lender's Name
.7 Z Lender's Address
J O 1 comfy that I have read this application and some Nat the aWvc information is
F comCL 1 agree an comply wit all city and county clearances and mute laws relating to
QU building construction.and hereby authorim reinisCO LIOC{Of this city to enter upon be
Ck1 above-mentioned properly for inspection Purpmes
(Wc)agree to save,indemnify and keep harmless the City of Cupertino against
r N Iiabilities,judgmcna.Cosa and expenses which may in any way acctuc against said City
C)z Al II'no=UNOCZE AofthNDS AofthnND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU ErtEGULATI S. z
YN J Re-roofs G/ ite
Signature ofA li nV Onvactor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will applicant or future Wilding aeupantstore or handle haumous material
I
defined by the Cupertino Municipal Code.Chapter 9.12.and he Health and Safety
a.Sadao 255320)? All roofs shall be inspected prior to any roofing material being installed.
0 Yes u
Wit]the applicant or future Wilding Occupant ase equipment or devices which -If a roof is installed without first obtaining an inspection,I agree to remove
cm it haixtea air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Darict?
0 YC' Q�k
1 have real she Wvardnus materials ropturco mats under Chapin 6.95 6.95 of she Calif.,
ria Had"Safety Cade.Section 25505.25533 and 25536.1 undcmomd this if to Wilding
docs not currently h • an.that it is my responihiliry to.01y the occupant of the
mquimmemas weir mums met priMtoissOana ora 'f ora parley. Signature of Applicant Date
ow or awhorizcJ age ate All roof coverings to be Class"B" or better