06070133 CITY OF CUPERON PER ONTRXIC-TO iVFOT.tMr�.TiON
BUILDING DIVISION PERMIT
BUILDING ADDRESS: RE POWER PERMIT NO.06070133
10873 WILKINSON AV
OWNER'S NAME: PERAff[LSUE DATE
PANNELL CHARLOTTE 1624 DELL AVE 07/20/2006
SANITARY NO. CONTROL NO.
(408) 927-0811
ARCHf1ECf/ENGINEER:
BUILDING PERMIT INFO
BLDC ELECT PLUMB MECH
0 0 0 0
so
LICENSED CONTRACTOR dunderSDECLARATION '^ Ih�^^ Job Description
w 1 Wreby affirm Wt 1 am(dOaad undo pmvidoa of chapter Y(commencing 11 V1 '
ii6 with Soction]IX1U)ofDivision 3afine Business and a ssioa Code��t yliccnxu
in full force andeffea ! 7 U � Iff OF A SOLAR ELECTRIC (PV) ON A
LiccnxLic.N
•moo Damconoam, d r RESIDENTIAL ROOF
ZZ ARCHITECTS DEAR
CLAII N ,/5
i K a I undersand my phna shall he used a public recordsu. y
ides
0 Licensed Professional
OWNER-BUILDER exempt
DER DECLARATION
)O C I mono .(Sure that 11. exempt(erre the fesnvazmh License c law for Ne
p O following recon.(Section t NB L5,Business mrd Improve.
knodi Code:Any an or county
n which requires•permit re co oust,alar,improve,hpermili nr repair ed soman
thior t W is liensedpalw requires lhivisioeant for ContratorUaransple a e Law(Chapter
D Ihnncincingxdpursuantta )ofDi,ii..3NeConuacmr'.dP,.claw(Clupim9 Sq.F[. Floor Area Valu Ib17
;5 s (commcs cammiidt scctionn and the baleian r of Nc B ed exem own.M Achilllon or
-5� eras he u eumpt muclrom and the bait for We alleged eampdan.My violation of
Section]BAS by any applicant(or a permit subjects the applicant o a civil parody of {�
nos ream than rive hundred dollars(5500). 3 PYi`-1`kt�yeC O O Occupancy Type
01.It mover of die property,a my employers with wages a Neo sic eompewdoq JJ O011Jv 'S
will do the work.and Neswemm is out intended ter offered fm sde(Sec.T(3N,Business Required Inspections
and Profesmoa Code:The Conmemes lilacs law doer oat apply m e an owner of q p
prosy no Wilss w imgow divorce,and who doessuch work nimtel(ar through bit
hmen oweer.me bu,providedinorimmsucn improvements,mid within
not intendedorar@red for Owner. �� ��
hones, me building terimprowmmtllstd within ane year ter completion,du ervnen
builder will have tn<burden of proving Na rte did ret Wild m improve for purpose of
sale.).
❑1,a owns,of the property,am ea.1movely comtraNng with account convenors to
construct the project(Sec.7044.Business and Professions Cade:)the Convectors U.
c.,Law dors not apply than nwnsr of property who builds or improves themoe,and t! , •t /7 �oO
whicenmacu u for such prejeewith acmntracmRs)Beenxd permission th the Committees / .tY 6
nse
Licetaw.
❑ I am exempt under Sec ,B&P C for this On t{�� (rt7 ryryAA\Bp LM -i"'
v,
Ower, PEIte LOW��� ,1���t(jl�r•-.n
WORKER'S COMPENSATION DECLARATION ��YYff
I hereby affirm under penalty of perjury ona of the following derlaratiorsz
1 ham and will maintain a Cerdfiate ter Consent to xlf-locum for Worker's Compem-
rmian,a Provided for by Section 5700 of dx Labor Ccul,far the performance of the
work for which this permit is issued.
❑I have end will..Irwin Workcls Compensation Insurance,has required by Sermon
57BO of the tabor Code.for the performance ofthe wart for which this permit is iauei.
My Workers ore�t es�ado mn¢pricr and Policynumhc,cam: •�/'
Cartier. . PT . l7 Policy No.: 1
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Thu xcd.need not be completed time pewit Is for enc hundred dollen(SIM)
or las.)
1 unify that in the perrmore'a of the wort for which mis permit is issued,l shall not
employ anyperson in any manners as m become abject in the Workere Compwadon
Laws ter Calironim Dam
APPliam
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
Weome subject to the Workcr]COmpeesation previsions of me labor Coat,you mug
.J 0 forthwith comply with such pow mans o,Nu permit dull be do med reversed.
EZ i CONSTRUCTION LENDING AGENCY
(-+ Ihereby whichgrim thatIMM4 nod(Sec. lending agency for me performance of
1' the war's Lar which Nu Permit u issocd(Ste.7119],Civ.C.)
M Q Lendcs Name
a
, z I<ndeh Address
U0 i certify that I haw read this application and sum mat lie show information is
ly (•' comacL 1 agree in comply with all city and county ordinances and state laws relating to
0 building construction.and hereby amhome representatives of this city to enter upon the
fr+ysnow-mentioned property for imil ection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
rq liabilities,judgments.cost and expenses when may In any way accrue agaed,son City
U Z in comequcnec of the granting of this permiL
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULATIONS,
Date
C �qw Data
signA :2
Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or future building occupant store or handle hvardaus material
u defined by tK Cupertino Municipal Code.Chapter 9.13,and the Hot and Safety
code.s tion us53(a)±
Ya All roofs shall be inspected prior to any roofing material being installed.
�}Nu
Will the applicant or future Wilding occupant use,equipment or dcvicn which If a roof is installed without first obtaining an inspection,I agree to remove -
it hava❑rdaus air canuminanu a dafncd by the Bay Aree Air Quality ManaPerim all new materials for inspection.
District?
❑res XNo
1 have mad the WraNma materials requircmcmu under Chap ird.95 of Ne Califon
nia Health&SarmyCede,Sections 255(15.35557 and 25SM.l understood mazifde Wilding
does not curremly have a temnt,mat is u my resparaibility m ratify the Occupant of the
regdmmana when xmet pytia�tu;a_,aanee ars Comr.am or apapansy. Signature of Applicant Date
/l"l�� " 7/a C�Oc
Owner or amnarizcd again DamAll roof coverings to be Class "B"or better
' '