07010136 CITE'OF CUPERTINO
BUILDING DIVISION PERMIT CT�iR NFf RMATI€�N�
BUILDING ADDRESS: PERMIT NO.
-)9820 Uit
TE
OWNER'S NAME:
IUTTON 01/30/2007
SANITARY NO. CONTROL NO.
...SNE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
4 p 0O LICENSED CONTRACTOR'S DECLARATION Job Description
qm r– I hereby affirm that I am licensed under provisions of Chapter 9(commencing
<i UW with Section 7000)of Division 3 of the Business and Professions Code,and my license is SOLAR F ROTO 70LTA I C SYSTEM ROOF MOUNTED
o. in full force and effec +
?�z License CI s Lic•# BORREGC SOLAR PAID BL 1/22/07
t„p Date
CatUW-
ARCHrfECTS DECLA A
R< 1 dcrstand my plans shall be used as public records
7ul
U.y Licensed Professional
O a OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
which requires a permit to constructalter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
a that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area $22000
YF (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of /�RN Number Occupancy Type
not more than five hundred dollars($500). 34221025 .lJ U
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
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 burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property.am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li.
cense 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 Contractor's
License Law.
❑1 am exempt under Sec. B&P C for this reason
r)wner Date
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 Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance ofJhe work for which this permit is issued.
My Worker's Compensation Insu cc ca Policy number am: 2,---)Cartier. "'c'No.:
CERTIFICATE OF EXEM ON FROM WORK RS'
COMPENSATI INSURANCE
(This section need not be completed if the permit is forone hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued.I shall 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 Labor Code,you must
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
z " CONSTRUCTION LENDING AGENCY
[~a cl) I hereby affirm that there is a construction tending agency for the performance of
pC > the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
0 z Lender's Address
;,,)0 1 certify that 1 have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating to
U building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for ins urposes.
nr (We)agree to save,i c 'y and cep h less the City of Cupertino against
,Ft
Co] liabilities,judgments,costs nscs hich y in any way accrue against said City
V Z in consequence of the g o is rmit. Date
APPLICANT UND ANDS D W Y WITH ALL NON-PO Issued t,y:
SOURCE REGU S.
Re-roof s
Signaturc ol`Applicanb o r Va Type Of Roof
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All rool's shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant orru."building occupant use equipment or devices which
If a foo�is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
C]Yes 100
I have read the hazard s materials require nts under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 05,25533 25534.1 understand that if the building
does not currently have a icnan is my re • r ity to notify the occupant of e
requirements which must be p r o issu of a certificate of occupan . Signature of Applicant Date
All roof coverings to be Class"B or better
Owner or authorircd age t a