08100075BUILDING DIVISION PERAM
22355
OWNER'S NAME:
PHOtg:
ARCHrrEGT/F.NGINEER:
r
3 O p LICENSED CON RACfOR S DECLARATION
V I hereby affiem the I am licensed under Provisions of Chapter 9 (commencing
with
S Ilion 7000) of Division 3 of the Business and Professions Code, and my license is
y in full farce and effect.
Z 6 lie. r
1 tieense
t Cmntrsctmr f +a� n r.�_
9 Dale ARCHrMCrS DECLARATION
oil I understand my plana shall be used u Publictecotds
3'U
cu- In Licensed Professional
y
W1 OWNER -BUILDER DECLARATION
J� X I hereby sffrm that I sm ammpt from the Contractors License Law for the
00 following reason. (section 7031.3. Business and Pmfdstiaca Code•. Any city or county
S which requires a permit to cmmnet. Rbc hnprore, demolish. err Repair any structure
prior to its issuance. also Require the appliam for such permit to file a signed sutemmt
z that he Is licensed pursuant to the pmviaknt of the Contractor's License Law (Chapter 9
F (commencing with Section 7000) of Division 3 of the Business and Prolhodons Code) or
that he is esempt therefrom and the beds for rho alleged exemption. Any violation of
Section 7031.3 by any applicant for a permit objects the applicant to a civil penally of
not mare than five hundred dollars (5300).
❑ 1. a owner of the property. or my employees with wages as their sole conipenedon.
will do the work. and the aornerme is not intended or offered for sale (Sec. 7044, Business
and Professions Code The Conraemfs I'-- Law don net apply m an owner of
property who builds or improves thereon, and who don such work hiaavif or through his
own employees, provided the such improvements are not ime ded or offered for ale. Il;
bowever the building or imptovanmt is sold within one yen of co mpletimm. the owner -
builder win have the burden of Moving that be did for build or improve for purpose of
❑ L as owner of the propertx am eclnsivdy contracting with Barred contractors to
construct the project (Sec. 7044, Bud— and Professions Code:) The Contractor's U.
own Law does not apply to an owner of property who buft or improves thenan, ami.
who contracts for such projects with a eomcaemr(s) licensed pursuant to the Contractor's
License Laws
❑ 1 am exempt under See B A P C for this mason
Owner Dan -
WORKERS COMPENSATION DECLARATION
AKEENA SOLAR
(408)867-0558
PERMIT NO.
08100075
PERMrr ISSUE DATE
A O. 9 9 8 CONTROL NO.
BUILDING PERMTr INFO
BLDG ELECT PLUMB MECH
Job Description
INSTL FLUSH ROOF MNTD SOLAR MODULES
Ft.
Mr -T, 9I1I1I 11111
Required Inspections
I hereby affirm under penalty of pnjmy one of the following deelantions
❑ I have and will maintain a Certificate mf Conrcm to self -lame far Workers Compen-
sation. u provided for by Section 3700 of the Labor Code. for die performance of the
work for which this permit is issued.
❑ I have and wig maintain Workers Compensation Insurance, u required ed by Sermon
3700 of die Labor Code, for the performance of the work for which this permit is issued
My Workers Compensation bwrsece artier and Policy number am
carrier _Policy No.: 1 3 -Sf.33
TIFICATE OF ExENFnON FROM WORKERS
COMPENSATION INSURANCE
(This section need not be completed U the permit is forone hundred dollars ($100)
or Ina)
I certify that in the performance of the work for which this permit is issued. I shall out
employ any person in any mover so u m become subject m rhe Woritc a' Compensation
Laws of California. Dam
Applicant
NOTICE TO APPLICANT. If, after making this Ceedfnam of Exemption. you should
.become subject to the Workds Compensation provisions of the Labor Code, you must
Ofanhwith comply with such provisions or this permit shall be deemed mvoked.
z 0.4 CONSTRUCTION LENDING AGENCY
E~ C07 I hereby affirm that them is a construction lending agency for the perfarmmice of
px i the work for which this permit is issued (see 3097. Civ. C)
a 0 Lenders Name,
Landers Address
U O 1 certify that I have red ibis application and stare rhe the shove information is
4. coned I agree to comply with all city and county ordinances and state laws relating to
O U building construction. and herehp mrhorin mpm=tadvcs of this city to enter upon the
W above-mentioned property for inspection purposes
(We) agree to are, indemnify andkeep bar lw rho City of Cupertino against
u.y N liabindes, judgments, Costs and expense which may in any way acme against said city
U Z in consequence of the granting of this permit.
-' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by:
SOURCE REGULATIONS. _ , , _ _1
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or had& hazardous material
as defined by de Cupertino Municipal Code. Chapter 9.12. and de Health a l Safety
Code. Section 25532(x)?
❑Yes No
Will the applicant or future building occupant on equipment or devices which
emit hazardous air contamiis ss defined by the Bay Area Air Quality Management
District?
❑Yes m 4,
I have read dare haardous marerials requirements under dupes X95 of the Canfar
nia HmiW & SaGdyCode, Sections 25M.25533 atdW34.1 undersand than if tie building
does not currently have a mount. that it is my nu, bilily to notify tle occupant of the
requirements m of Occuprtcy. -
Re -roofs
Type of Roof
Valuation
Date / NG G 1
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's' or better