08110024CTTY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
11073 W
OWNER'S NAME:
ARCHI' ECffENCrTNEERi
a O 0 LICENSED CONTRACTOR'S DECLARATION
Cur! I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
Z with Section 70W) of Division 3 of the Business and Professions Code, and my license is
n ? H in full force and e p
i 3 ucnme a I. • �-� l O
1 F Date — Contract.,
Krr—
ARCHMECTS DECLARATION
1 understand my plans shall be used as public retard,
�yU
# u. Lid Prvfemonal
0 OWNER -BUILDER DECLARATION
nn
t I hereby affirm that 1 am exempt from the Contractors License Law for the
is G 0 following mason. (Section 7031-5, Business and Professions Cale: Any city or county
R $ which requires a permit to construct, alter, improve, demolish. or repair any structure
y y prior to is issuance, also requires the spplkant for such permit m file a signed statameni
G that be is licensed pursuant to the provisions of the Contractors Llano Law (Chapter 9
$ (commencing with Section 7000) or Division 3 of the Business and Professions Code) or
y .. that he is exempt therefrom and the bask for the alleged exemption. Any violation of
Section 7031.5 by my applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S500).
❑ 1, as owner of the property. or my employees with wages as their sole compensation.
will do the wort, and the structure is not intended or offered for rate (Sec. 70"; Business
and Prutessiiom Code The Contractors License Law does not apply to an owner of
property who buikfa or improves thereon, and who does such work himself or tMmagb 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.).
❑ I, as owner of the property. am exclusively contracting with licensed contractors to
construct the project (sec. 7044. Business and Professions Code:) The Contractors UT-
cense Law does not apply to an owner of property who builds or improves tbereon, and
who contracts for such projects with a contractor(s) Bcertmd pursuaut to the Contractor's
License Law.
❑ 1 am exempt under Sec. B & P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following deekntioms
❑ 1 have and will maintain a Certificate of Consent to self-insum for Workers Compen-
sation, AA provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued
❑ 1 have and will maintain Worker's Compensation Innate, as Tcquked by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My
FROM WORKERS
COMPENSATION INSURANCE
(This ration need not be completed If the permit is for one hundred dollars I$100)
or Less.)
I certify that In the performance of the work for which this permit is issued. I shall not
employ any person to any manner so as to become subject to the Wodmrs' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT`. If, after making thU Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
,7J O forthwith comply with such provisions or this peanit shall be deemed revolted.
a C12 CONSTRUCTION LENDING AGENCY
[� h� 1 hereby affirm that them is a construction lending agency for the performance of
Ct. > the work for which this permit is issued (Sec. 3097, Civ. C.)
a A Lender's Name
Lenders Address
U O 1 certify that I have mad this application and aim that the above informadou is
LL correct. 1 agree to comply with all city and county ordinances and state laws relating to
O V building consm"on, and hereby authorize reprtsentatives of this city w enter upon the
U above-mendoned property for Inspectlan purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
Eel liabilities, judgments. costs and expenses which may in any way accrue agaist said City
U 7 in consequence of the granting of this permit.
t� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Signature of ApplicanVCon,actor Deese
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haardous material
as defined by the Cupertino Municipal C Cbapter 9.1Z and the Halth and Safety
Code, Section 25532(a)?
❑ Yes
Will the Applicant or future building occupant use equipment or devices which
emit hazardous air contaminants all dell by the Bay Area Air Quality Management
Disuiv?
❑ Yes o
1 have mad the ha7wde s materials requhca mu under Chapter 6.95 of the Califor-
ma Health & Safety Code, Sections 25505.25533 and 2"N.1 understand that if the building
does
of jkcu,Fancyi �.�
(888)657-652
PhRmur NU.
PERMIT ISSUE DATE
ees CONTROL NO,
BUILDING PHRMrrINFO
BLDG ELECT PLUMB
Job Description
SOLAR PV SYSTEM FLUSH MOUNTD ON ROOF
Sq.
APN Number
35617035.00
Required Inspections
Issued by:
Re -roofs
Type of Roof
Valuation
Type
Date ff 2 !re.
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
Date