07060019 CITY OF CUPERTINO
BUILDING DIVISION PERMIT � 'R� � I '
PERMIT NO.
BUILT1>UrO5EsMERRIMAN RD 2THORIZON ENERGY SYSTEMS 07060019
U PERMIT ISSUE DATE
OWNER'S NAME:
GROMI MARY P 0 BOX 320612 06/13/2007
SANITARY NO. CONTROL NO.
)NE:
(408) 395-9060
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
0
p C LICENSED CONTRACTOR'S DECLARATION Job Description
m 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is ROOF MOUNTED SOLAR SYSTEM
in full force and effect. 3
v�Z License Cla�c C 6 Lic-8
Date 6-i 3^a'> Contractor
W ARCH1TECf'S DECLA O
i a< I understand my plans shall be used as publi records
>yU
a Licensed Professional
y OWNER-BUILDER DECLARATION
> 1 hereby affirm that I am exempt from the Contractor's License Law for the
3 p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
ems,(i which requires a permit to construct,alter,improve,demolish,or repair any structure
y prior m its issuance,also requires the applicant for such permit to file a signed statement Valuation
z r Ft.Floor Area $36000 that he is licensed pursuant to the provisions of Contractor's License Law(Chapter 9 `Sq $3 6 0 0 0
t--$ (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 34216099
�Number Occupancy Type
not more than five hundred dollars($500).
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
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 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.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contracwr's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractar(s)licensed pursuant to the Contractors
License Law.
❑1 am exempt under Sec .B&P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure for WOrkces Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
0 I have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Compensa on Insurance carrier and Policy number arc:
Carrier. —STAlk 1V Nd Policy No.: -125-2
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
((his section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued.I shalt 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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
z, CONSTRUCTION LENDING AGENCY
E r CA 1 hereby affirm that there is a construction lending agency for the performance of
p:> the work for which this permit is issued(Sec.3097,Civ.C-)
W Q Lendces Name
z Lender's Address
V I certify that I have read this application and state that the above information is
[L. correct.1 agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorize representatives of this city to enter upon the
C>a above-mentioned property for inspection purposes.
L>r (We)agree to save,indemnify and keep harmless the City of Cupertino against
,may Ci) liabilities,judgments,toss and expenses which may in any way accrue against said City
U z in consequence of the granting of this permit. Date
►'" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b•/:
SOURCE REGULATIONS.
Re-roofs
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE Type Of.Zoof
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)? All roof:,shall be inspected prior to any roofing material being installed.
❑Yes Q!kNo
If a roof is installed without first obtaining an inspection,I agree to remove
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 all new 1 naterials for inspection.
District?
❑Yes ONo
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safcty Codc,Sections 25505.25533 and 75534.1 understand that if due building
docs not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements whic=,et suance of a Certificate of Occupancy. Signatur'r of Applicant Date
6 -1 9-o All roof coverings to be Class"B"or better
Owner or authod7,00d agent Date
CITY OF CUPERTINO
ITEM 1 OF 1 PERMI`C RECEIPT OPERATOR: bethe
COPY # 1
Sec: Twp: Rng: Sub: Bl:c: Lot :
APN 34.216099 . 00
DATE ISSUED. . . . . . . : 06 /04/2007
RECEIPT # . . . . . . . . . BS)00001536
REFERENCE ID # . . - : 07 )60019
SITE ADDRESS 10555 MERRIMAN RD
SUBDIVISION
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER GRDMI MARY
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-3921
RECEIVED FROM HORIZON SYSTEMS
CONTRACTOR BRUCE GORDON LIC # 25713
COMPANY HORIZON ENERGY SYSTEMS
ADDRESS P S BOX 320612
CITY/STATE/ZIP . . . : LOS GATOS, CA 95032
TELEPHONE (408) 395-9060
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- -------
SOLARRES FLAT RATE 1 . 00 300 . 00 0 . 00 300 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 300 . 00 0 . 00 300 .00 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 300 . 00 MASTERCARD
---------------
TOTAL RECEIPT 300 . 00