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CITY OF CUPERTINO
BUILDING DIVISION PERART
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393 VINTAGE PARK DR STE 140
09/03/2008
PHONE
SANrrARY NO. CONTROL NO.
(650) 638-1028
ARCHTIECTIENGINEER:
BURRING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
9
Job Description
I hereby affirm that I am licensed under provisions of Chapter (commencing
with Secdort 70D[Y) of Division 3 of the Business and Professions Code, and my licenst: is
ROOF FLUSH MOUNT PHOTO VOLTAIC SYSTEM—THE
in full ova and erect. Lie. g eb$
Lice r, S
GRID -TIED INVERTER SHALL NOT BE LOCATED CLOSER
Dam ARCHITECTS DECLARATION
THAN 3 FT OF THE NORTHEASTERLY PROPERTY LINE(LEFT
1 understand my plans &hall be used as public records
Licensed Professional
GWNER-BUILDER DECLARATION
I hereby &Mrm that I am exempt from t)ne Contractor's License Law for the
following reason. (Section 70315, Business and Professions Code: Any city or county
which requires a permit to consu tM alter, improve, demolish, or repair any structure
prior to its Issuance. also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractors Umnse Taw (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) or Division 3 of the Business and Professions Cafe) or
$ 2 5 0 0 0
that he is exempt therefrom and the basis for the alleged exemption. Any violaiion or
Occupancy
Pcane Y Type
Section 7031.5 by any applicant for a permit subjects the applicant to a Civil penalty of
ypp Number
3 621603 0
not more than rive hundred dollars ($5M.
. ti
❑ L as owner of the property, or my employers with wages as thew sole compensation,
.
Required Inspections
will do the work, and the structure is not intended or offered fortalc (Sec.7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
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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 burdens of proving that he did not build or improve for purpose of
❑ L as owner of the properly, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Conttutors U.
coax Law does not apply to an owner of property who builds or improves thereon, and
,
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
I icense Law.
❑ 1 am exempt under Sec . B & P C for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -Insure for Workers Compcn-
'
salon, as provided for by Section 3700 of One Labor Code, for the performance of the
work for which this permit is issued
I have and will maintain Workers Compensation Insurance, sa required by Section
of the Labor Code, for the performance of the work for which this permit is issued
My Workers Compensation Insurance carrier and Policy number am:
-
carrier- ZArtcli P:fL"LPolicy No.: Or=gh:1-J4lbo7
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CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or less)
I certify that in the performance of the work for which this permit is Wood. I shall not
employ any person in any manner so as_to becorpe subject to the Worked Compensation
Laws or Cal' fa. Dam l rya
Applicant 1W J22,V
NOTICE TO APPLICANT: Ir, after making this Certificate or Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this peanii &hall be domed revoked.
—
CONSTRUCTION LENDING AGENCY
I hereby affrm that there is a consutxtion lending agency for the perfortnanec or
the work for which this permit is issued (Sa. 3097, Civ. C.)
Lender's Name
1.4ndcr's Address
I Certify that I have read this application and state that the above information is
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correct 1 agree to comply with all city and county ordinances and state Im relating to
building eonswction, and hereby anthmvn mpresentarives or this city to enter upon the
above -mentioned property for Inspection purposes
(We) agree to save, indemnify and keep harmless the City or Cupertino against
liabilities, judgments, costs and expense which may In any way accrue against said City
in consequence of the granting of this permit'
APPLICANT UNDERSTANDS
the applicant or future building occupant store or handle hazardous material
as dt ined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code, season 25532(a)T
❑ Yes ETNo
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contamLtants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes
1 hevc read the hazardous materials requimmmis under chapter 6.95 of the Califor-
nia Health & Safety Cade, Sections 25505.25533 and 25534.1 undumand that if the building
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does not currently have a tenant. t as It is my responsibility to notify the occupant of the
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requirements
roof coverings to be Class'j4" or better
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Owner or authorized agent