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BUILDING DIVrSION PERMIT
BUILDING ADDRESS:
10427 AVENIDA LN
OWNER'S NAME:
TOM DEACON
NE:
ARCHITECTIENGINEER:
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect
License Class L Lic. N
Date OC.20-91 _ Contractor so arur
ARCHITECTS DECLARATION
I understand my plans shall he used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
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
not more than five hundred dollars ($500).
[:11, as owner of the property, or my employees with wages as their sale compensation,
will do the work and the structure is not intended or offered for sale (Sec. 7044, Business
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 We. 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.
cerise 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 Contractors
License Law.
❑ 1 am exempt under Sec . B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
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-1 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
tation, 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 of the work for which this permit is issued.
My Workees Compensation Insurance carrier and Policy number arc:
Carrier.!{ F!k& Q' a�_N olicy No.:V05 OMO \kg
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is foronc 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
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a constructinn lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
I 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
building construction. and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit
APPLICANT DERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE RErjULATIONS,
01,
Signature of pplicam/Contractor Datc
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)?
Yes 4No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ yes eNo
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & cry Codc' Seniors 25505, 25533 and 25534.1 understand that if thc building
does not et tly have a tenant that it is my responsibility to notify the occupant of the
requircmen hick must be met prior to issuance of a Certificate of Occupancy.
Owner ol4uthorized agent _ Date
PERMIT NO.
AKEENA :SOLAR, INC 07060072
-- PERMIT ISSUE DATE
605 UNIVERSITY AVE 06/20/2007
SANITARY NO. CONTROL NO.
(408)86"-0558
BUILDING PERMrr INFO
BLDG ELECT PLUMB
Job Description
INSTALL 24 ROOF MOUNTED SOLAR MODULES
sq. Ft. Floor Area
34245043Number
Issued by
Re -roofs
Type of Roof
$30000
Required Inspections
Valuation
occupancy "lype
Date (�j " q o
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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 rr aterials for inspection.
Signature of Applicant
All roof coverings to be Class "B" or better
Date