04090237 (3) CITY OF CUPERTINOrraa�nsa , * > ,a�;^.
BUILDING DIVISION PER CONTRACTOR INFORMAWN
BUILDING ADDRESS: - REGRID NPOWER PERMIT NO 04090237
R'S NAME: PERMIT LOVE DATE
LUTF
PHONE: SANITARY C OL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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too
LICENSED CONTRACTORS DECLARATION Job Descrip
I hereby aUlne that I Am licensed under provisions of Chapter 9(commencing
Zj with Section 70,M)ofDMMear 3o(the Business and Professions Code,aad my license is
^<� in full force and effect, oZ,;R S PHOTOVOLTAIC SYSTEM
LiA. LIe M NOV l0 2004
car Date "".0-or_ O Vtf
q ARCHITECTS DECLAKAT !
�y a 1 understand my plans shall W used As public records
BUILDING
yud Licensed Professional
OW NER.BUILDBR DECLARATION
I hereby.(Sere that 1 1. exempt from the Contractor's Co License Law for the
F.O O following Lues A Permit
t BDL3,Business and ova. asimts Cade:My city or county
se$ which requtms n eemdit to tura,tk alre,imparsu demolish,er repair any mnctun
v_i
text
m its issuance.pursuant a4u mquirte the applicant for Con permit to fit.Lewd anemen
vix=a them Min licensed Sectioodta ofDivision
iviomof theeBusinessWromciaw(C Code)
Sq. Ft. Floor Area Valuation
s-$ teat he is(commencingwith
dominant
t and due basis for out al Business and Prorcaon.Any
Cndc)ate
that he u exempt Nem(rom and Ne basis for the alleged exemption.Any violation of
Section 7031.3 by any applicant for a permit subjects the Applicant m A civil penally of 3 649MI60C,10 0 Occupancy Type
nm mon Nut five hundred dollar.(5500).
❑1.u owns of stie propmy,m my cmploycu with wagex ss th'v Wlerompewdon.
will Pr rmi...endo: h.o m act en¢ndedmoRendess Am apply t an
Owner
Required Inspections
And Professions Code:The Cna datum t,License Law does nos Apply m an owner of q P
propertywhobutIdaorimproves Nemon,endwho doesotech work rooffforthrough his
own a however,
the Wilding
that such impmwments ere not landed moRemd for Owner.. .
bull&' Nebuilding orimprovement ishat withinone year ofcompletion.the ase of
builder will have the burden of proving Nes he did not Wild or improve for purpose a(
sal..).
❑1,As owner of 0e Property,am exclusively contracting with licensed contractor sec
convect ase project(Sec.7044,Business and Profession Code:)The Conwcmm's Li-
cense,law does not apply As an owner or property who Wilde or improve thereon,and,
who common;for such projects with a contractor(s)licensed pursuant to the Conrrttofs
Leena Law.
I ren exempt under See ,B&P C for thio myon
<r Date
WORKERS COMPENSATION DECLARATION
I hereby arm under penalty of pedwy one of ft following dechralions:
❑I haw and will maintain a Cenifienta ofCcasent 1.self-Imarepar WarkefaCompen-
ssaan,As provided fm by Section 3]00 of the Labor Code,for the pclf...ncA of the
walk(or which Nis permit is issued.
I haw and will maintain Workcfs Compewsion Insurance,ss required by Section
3 of Ne Labor Code,for the performance of the walk for which this permit is issued.
My Walker. p pemation In utance amiss and Policy number art:
Came Policy No.:Q2E 9.9 valid
CERTIFICATEOFEX ..N PROM WORKERS'
COMPENSATION INSURANCE
(ITh section Weal not hecomplewl if the permit is for onchundreddollan(5100)
or ins.)
1 certify that in the performance of the work for which Nis permit is issued.I shall not
employ any person in any mwncrso as to become subjecl to dsa Worker'CamPenation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,eftm making Nis Cenifiu¢of Exemption,you should
become subject he the WmkefA Corepenauon provisions of the Labor Code,you muss
O forthwith comply with such provision or Nis Permit hall W deemed revoked.
.ziy CONS11UCrION LENDING AGENCY
F+ hereby af(Irm dam there is a convection lending agency for the performance of
a> the work(m which this permit is issued(Sec.3097.Civ.C.)
Uj
IM Lenders Name
�z Lenders Address '
U C) I certify that 1 haw mad this Application and Aute Nn the above information is
H correct.I agree to comply with all city and county malmnm and state laws mtaang to
p V building construction,and hereby andamine representatives of this city to enter upon du
>'d &hove-mentioned properly far inspection purposes
(We)agree to sew,indemnify and keep harmless the City of Cupertino against
dF"•i CA Iiabiliuo,judgment,costs and espmtaes which may in any way avenue agemasald City
V z in APPLIC NTeUNDERSTANDS Aof Me graming ofIND WILL COMPLY WITH ALL NON-POINT Issued by:9102� Date
50 E REGULATIO S.
n� /n0_-:�.� y/zJLO 5 Re-roofs
'Signature of Applic �Coauacmr I Dole
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will she applicant or furan Wilding occupant more or handle hvndom material
fined by the Cupertino Municipal Code.Chapter 9.13.and the Hea1N and Safety
.Seed..25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes I(Nu
Will the applicant or om;future&building bydo,Occupant tax equipment Of devices which
If a roof is installed without firs[obtaining an inspection,I agree[o remove
amts harndnuA air contminanu v dc0ncd by the Bay Arca Air Quality Management all new materials for inspection.
DiWiel?
❑Yu lB'rrq -
1 have mad the hanrdous materials requirements under Chapter 6.95 of the Califor.
nia Health&SafmyCode.Secants 25505,25533 and 8534,1 understand Nm if the Wilding
dons nos currently haw A tenant Nm it h my responsibility w redly sW occupant of the a
aqui nu which mum W met priormisuuce.fa CeraOceuof Occ72
p cy. IgnatUre Of Ap cant ate
�Per lywo(!D,o e y ZI a All roof coverings to be Class"B"or better
04m,oraumhmi.datAl are