08090188 CITY OF CUPERTINO
BUILDING DIVISION PERMITCONTRAC (:1RINk'O_RMe�TIO.,MN
BUILDINGADDRESS: PERMITNO.
834 ROSE BLOSSOM DR COBALT POWER SYSTEMS, INC 08090188
NER'S NAME: PERMIT ISSUE DATE
SMITH BARRY A AND DEE T 2444 OLD MIDDLEFIELD WAY 10/07/2008
PHONE: 011 o SANITARY NO. CONTROL NO.
(650) 938-9574
ARCHiiER/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
O o LICENSED CONTRACrOR'S DECLARATION
miI baaby affirm that i am lived under provisions of Chapter 9(commencing Job Description
with Smbasn'")ofl)ivhdon 3 ofte BusircuaM pmesslev Codc,aM my licenseis INSTL RF MNTD .PHTOVOLTAIC .SYS(NO BTTRY BKUP)
<N in full forte ahaefr , O
uaeve Cl Lle.g
ARCHRHCI'S DECLARATION
1 uMcrmanJ my putts shall W orad as public rmoNs
1a�
g0 Lkeved Professional
c m 3 Oat I am exempt
DECLARATION
C<E I hereby.(Sec on 1 L exempt(core the Canhactors License nso Law for Oe
00 fallowinguires a. emien 7 a1.3,Business aha vve,de uv Cale:Any em at county
C$Pi which its
issuance.permit re corwvn.alter,impvw,demolish,fi mpnir any stnucere
�Za priorbslcened P. rc tone deappliem for sochmsetoe mfile.Lawdsuement
0 thaleand.,; it pursoont to the pmvisiatu errtWConuacmrs llconselaw(Cluper9 Sq.Ft. Floor Area Valuation
E52 tat he
exempt
Section7000)and)MDivlsion3 theWBusmen anion.M art Code)Or $20607
Q — Nat k u samba.therefrom and the.perm for the alleged exemption.to Any violation of
Sedan]than by any red dont r«.permit m.jcns the applicant m a trail porosity Of Number Occupancy Type
not mom than fiw hundred dollen(SSW). 35904020 � p y YF
❑I,a owner of the pmpmty,err my employees with verge n them sole compenmd.,
will do the work.and Ne structure ls Out mounted or offered for gala(Sec.AM4.Busionas
and Profawmu Cable:rise Canmcmrs Liccve law dap cot appy to an owner of Required Inspections
property who Wildamimpmwa duxcon,and whodaameltworkhima forthrough bar
own cmplopxs,provided that such improvanmts sea not intended oraffazed formic.if. .
howova,the Wilding or impmseme rt is mid within one year of cavpletion,the ownee-
Wilder will have de burden of proving that he did.t Wild err improv for purpose of
cob.}
0 1.as owner of the property,am anumealy contracting wit BcMxd cantranon to
construct the project(Sec.7044.Business and Profeamos Code:)The Contractor's U.
cease law dap not apply to an owner of property who Wids or improve thetcon,and
who contracts for such projects with a Monomania)lic nmd punvnt m the Can=10es
Isevm law.
❑Iamaemptunder Sec. .B&PCfarthlsmnoo
40 rc Dan
WORKER'S COMPENSATION DECLARATION
I hereby amore maker penalty of Minty one of the following declsntiasc
❑I ham and will maintain sCertiBate of Consent to self-insure For.Workers Comper.
mesh for r pro h this
(or m $;mere 3]00 of the uWr Cade.(err the perfonnm.of the
which Nis acomit ls ia.d.
❑1 haw and will maintain Workers Cemprnntion Insurance,as required by Section
3700 of the Labor Code.far tW performance of the work for which this permit cleaned.
MY 'Tn
Workers CompenuW
donn ur�an W,carrier Policy number am:
Cartier. CViort 5l /0 NT a/ Policy No.: O
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ITB sonless teed act be complebed tithe permit Is for am hundred dollars(SIM)
orless)
1 arty Nat in the pmIcameme of the work fa which Nin permit is leant.I shall.t
employ any person in any mamerso as m harem subject to the Waders'Compound.
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Eacmpti.,you,slmubt
become subject to to Workers Compensation provisions of the Labor Cordo you must
O forthwith comply with such pmvistoru or this permit shall W dmmud.1seel.
Z'-" CONSTRUCTION LENDING AGENCY
hereby affirm than Nem is a conrtmdon lending agency fm to lcrfo.ancu of
oriti the work for which this permit ts mood(Sm.3097.Civ.C.)
0. Landers Name
.7 z Leade'sAW.
U O 1 mtify that 1 haw mad W.mplic ti.and sum that the also.information in
IT,
^. corral I"rte"m comply with all city and county artirrmm and ante laws relating m
C) Wilding construction.std thereby authorize mpmaentstixa of Nis city m count upon the
r[a.7 above-mmtiated properly fa inspection purposes
t„r G (Wer)agree to saw,indemnify and keep harmless the City of Cupertino against
rn liabilities,judgments,costs and exp••..an which may in any way accrue against said City
Uz in catsext.of the{noun{of this permth. zoif
ti APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
50 E TIONS. /�
Cna�c�t /�� I6/--1 D67, Re-roofs
Si{rutum of AppliaADeun
HAZARDOUS
xAZARDOURDOGS MATE RIALS DISCLOSUREhandle
Type Of Raaf
WIII y t applicant err forum Wilding Code.Chapt store err handle Real anmaerial
OcOnad DY dun Cup;ni.Municipal Chapter 9.11,and the Health and Safety '
.Section 25532(a)] All roofs shall be inspected prior to any roofing material being installed.
❑Ya �Ne
Will the applicant or future Wilding occupant can equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haaNnv err c.tsminaats a defined by the Bay Area Air Quality Management all new materials for inspection.
Dimint
❑Ya No
I haw mad the haardov materials equbem rds under Clamber 6.95afthe Califor-
.1.Health&Salty Cade,Sectiorts 25505,M533 ard 25534.1 undcrsmnd tba lfthc Wilding
does Out currently haw a ern L dart it u my responsibility m of,ire ocsupmt of the
mqu' c xnhmtwW riarmimuameohcortar Munnt Date
TP ramm Signature of Applicant C I i�ra l All roof coverings to be Class';W'or better
Owner a authorized agcm Dam"
C