08080025CITY OF CUPERTINO
BUILDING DIVISION PEWSM
;
BUILDING ADDRESS:
PERMrr NO.
20925 PEPPER TREE LN
HORIZON ENERGY SYSTEMS
08080025
OWNER'S NAME.
PM MIr EWE DATE
P 0 BOX 320612
08/12/2008
PHONE:
SANITARY NO. CONTROL NO.
(408)395-9060
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION
ZI hereby afErm that I um lWanxd under provisions of chapter 9 (commencing
Z � with Section 7000) of Division 3 of the Business and Professions Code, and my license is
r H in full finez arta ?.R S
)I z License Lie. ■
t-
Date -
002 Contractor WO
ARCHITEC!'S DECLARATION
d
U I understand my plans shall be used as public records
e wo in Licensed Professional
b yOWNER-BUILDER DECLARATION
1 hereby altimt that 1 am exempt from the Contnetar's License Law for the
in O following reason. (Section 7031.5, Business and Professions Code: Any city or county
$ 9 which roqui a a permit to construct. alter, improve, dcmollsh, or repair any structure
_ prior to its issuance, also requites the applicant forsuch permit to r a sighted statement
_ that be is licensed pursuant to the provisions of the Conuactoes license law (Chapter 9
t- (commencing with Section 7000) of Division 3 of the Business and Profession Code) or
that he is exempt tbesdrmm and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a dQ penalty of
not moue than five hundred dollars (5500).
❑ 1, as ower of the propvty, or my employees with wages as their sole compensation,
win do the work. and the suucbue is not intended or offered for sale (Sex. 7044, Business
and Professions Code: The Contractors License Taw does not apply to an owner of
property who builds or improves theme. and who dos such work himself or through him
own anployces, provided that such improvemrnttt ate not intended or offered for sale If,
however. the building or improvement is sold within am year of completion. the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ 1. u owner of the property, am exclusively contracting with licensed eonuaetors to
construct the project (Sm..7044. Business and Professions Codw) Ton: Co aaeto's L(-
conse Law does not apply to an owner of property who builds or improves thereon, sad
who contracts for such projects with a contractor(s) licensed pursuant to the conuactoes
I.leenae Taw.
❑ 1 am exempt under Sec B & P C for this mason
Owner Date _
WORKER'S COMPENSATION DECLARATION
I hereby afrum under penalty of perjury am of the fallowing declarations
❑ I have and will maintain a Certificate of Consent to self -insure for Workees Compen-
sation, u provided for by Section 3700 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
37W of the Labor Code, for the performance of The wok for which this permit is issued.
My Worker's Compensation Insurance wrier and Policy number ate:
Curies. Li 4cj 'CG Policy Na: _3a 1 7 ( 3 3
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Olds section need not be completed if the permit is for one hundred dollars (s IDD)
or less)
I certify that in the purfatmance of the work for which this permit is issued,) dull not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws 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 Lebo Code, you must
Z fonhwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCnON LENDING AGENCY
H ��-+ 1 hereby affirm that there is a construction lending agency for the performance of
Cli 5 the work for which this permit is issued (See. 3097, Civ. C.)
Rwi Q Lender's Nxme
z Lendees Address
V Q 1 unify that I have rad this application and state that the above information is
V. r" cosem l agree to comply with all city and county ordinances and state laws relating to
0V building construction, and hereby authorize representatives of this city to enter upon am
above-mentiompi property for inspection purposes
H a (We) agree to save, indemnify and keep harmless the City of Cupertino ageing
e„ y W liabilities, judgments, costs and expenses which may in any way accrue against said City
V Z to consequence of the granting of this permiL
" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous; muaial
as defined by the Cupertino Municipal Cade, Chapter 9.12. and ata Health and Safety
Cade, Section 25532(x)7
❑Yes AtRio
Will the applicant or future building maupant Use equipment or devices which
emit haixtious air contaminants as defined by the Bay Area Air Quality Management
Diarict7
❑ Yes ;8No
I have read the haatdaus materials mquimments underChapterti.95 of the Califor-
nia Hcalth & SafetyCodc, Sections 25505.25533 and 25534.1 understand thxtif tete building
does not currently have a tenant. that it is my responsibility m notify the oceupatl of the
tcqu which must be met) to issttetxq,of^ 'ayficgtc9f
Job Description
PV(SOLAR ELECTRIC)GRID-TIE SYS FLSH MNTED; NO
BATTERIES
Sq. Ft. Floor Area $30341 Valuation
3 5912014.W Number Occupancy Type
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date
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
all new materials for inspection.
Signature of Applicant
A
Date