08090049BUILDING DIVISION PERNUT
BUILDING ADDRESS:
11487 L
OWNER'S NAME:
ARCHITECT/ENGINEER:
O LICENSED CONTRACTOR'S DECLARA770N
u 1 hereby affirm Wit I am licensed under provisions of chapter 9 (commencing
with Section 71X10) of Division 3 of tie Businev and Professions Code, and my license is
' ca in full force and
Sim m License class
q h, $ Dae Conutraelar d Y
9 CHITECC8 D TION
I understand my plans shall be used as public records
�yU
`Q Licensed Professional
y 3 OWNER -BUILDER DECLARATION
S 1 hereby atTin a that 1 am exempt from the Contractors License Law for the
p O following won. (Section 70313, Elude= and Professions Code: Any city or county
Pi which requires a permit to construct, alts improve. demolish. or mpair any structure
prior lo its iatumee, also requires the applicant for such permit to file a signed aWanmerm
< that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
ZF $ (commenting with Section 7000) or Division 3 of the Business and Professions Code) or
y — that he is exempt therefrom and the basis for the alleged exampdon. Any violation of
Section 7031.5 by my appowt for a permit subjects the applicant to a civil penalty of
mot more Wan five hundred dollars (5500).
❑ 1. as owner of the property, or my employces with wages as their sok compensation,
will do the work, and Use structure is not intended or offered for sale (Sec. 7044. Business
and Profai ions Cock: The Contractors License Law dos not apply to an owner of
property who builds orimproves thereon. and who does such work himself or through his
own employees, provided that such improvements are not intended orotfered fa sale X.
however. the bdWng 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 erchnsively contracting with licensed contractors to
construct the project (See. 7044. Business and Professions Code:) The Conuactoes U.
rose Law does not apply to an owner of property who builds or improves themon, ani.
who contracts for web projects with a cemuatoda) licensed pursuant to the Contractors
License Law.
❑ I we exempt under Sec. B & P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby aIDm under penalty of perjury one of the following declarations
❑ I lave and will maintain a CrrtiOcate orConsent to self -insure for Wafts a Compeer•
sation. as provided for by Section 3700 of We Labor Code, for the performance of the
work for which this permit is issued
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
3700 or the Labor Code, for the performance of the work for which this permit is iasned
My Worl a'a C rem iept Insursncartivttand Number are:
Cartier: Lin
Policy a..
CERT911t4TE OF EX ON FROM WORKERS'
COMPENSA77 NINSURANCE
((his section need not be completed i<the permit is for one hundred dollars (S 100)
or leu)
1 certify that in the performance of the work for which this permit is issued l Awl not
employ any pence in any manner so as to become subject to the Worked 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
vJ O forthwith comply with such provisions or this petmit shall be deemed revoked.
Z � CONsmuc 10N LENDING AGENCY
E -e ►+ I hereby affirm that them is a comar ctian lending agency for the performance of
�e > the work for which this permit is issued (Sec. 3097, Civ. C.)
Q (.enders Name
z f.mdees Address
U 0 I ratify that I have road this application and state that the above information is
IX. " ' correct. I ages to comply with all city and county ordinances and stag Laws relating to
0 Fr building construction, and hereby authorize representatives of this city to enter upon the
FU &love -mentioned property for inspection purposes
a (Wer) ages to save, indemnity and kap ha mleu the City of Cupertino against
y y liabilities judgments, cuts and expenses which may in my way accrue against said City
U z in conrequentt of the granting of this perudL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE
/Dail
HAZARDOUS MATERIALS DISCLOSURE
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 25332(&)?
❑Yrs
Will the applicant or future building occupant use equipment or devices which
emit hnardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Yes eWNO
I have read Ute 6arsrd17— euts matcriab nuxpirements under dapter6.95 of the Califor-
nia
alifornia Health & Safety Code. Stations 25505.25333 and 25534.1 understand Wtdif the building
dors
a Ccnillcae of Otcupapry. I
510) 843-111
Job Description
PV(PHOTO-VOLTAIC)INSTAL
Ft.
APN Number Occupancy Type
35624005.00
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
Date
All roof coverings to be Class 'V' or better