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BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
10955 BARRANCA ng
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OWNER'S NAME:
PERMIT ISSUE DATE
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650 938-9574
ARCHT ECifENGINEER•
BUILDING PERMrrINFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I arm licensed under provision of chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Profession Code, and my license is
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RF MNTD PHTOVOLTAIC SYS (NO BATTRY BACK—UP)
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�effect.
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1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following mason. (Section 7031.3, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any swctum
prior to its issuance, also requires the applicant for such permit to file a signed statement
Ft. Floor Area
Valuation
that he is licensed pursuant to the provision of the Contractors Llcerne Law (Caapter 9
Sq.
(commencing with Section 7000) of Division 3 of the Business and Profession Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
S37452
APN Number
Occupancy Type
Section 7031.3 by any applicant for a permit subjects the applicant to a Civil penalty of
not more than five hundred dollars (5500).
32601007 .00
❑ L as owner of the property, or my employees with wages as their role compensator,
Required Inspections
will do the work, and the sbuctum is not intended or offered for sale (Sea 7044, Bushtess
and Profession Code. The Contractors License Law does ant apply to An Owner of.
property who builds or Improves thereon, and who does such work himself ar thmugh his
own employees, provided that such improvements are not intended or offered forsale. 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 (sex- 7044. Business and Profession code:) The contractors Li-
cense 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 be the Contractors
License Law.
❑ I am exempt under Sec- B & P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of the following declaration
❑ 1 hsve and will maintain a Cenificam of Consent to self -insure for Workers Compcn-
saton, as provided for by Section 3700 of the Labor Coda for the performarrm of the
work for which this permit is issued.
have and will maintain Workers Compensation huurma, as required by Section
'3100 of the Labor Coda for the performance of the work for which this permit is Issued
My Wor�kers, qCompensation Insurance carrier and Policy number are:
CLrtier.C.�7t- ��t i'F►� -�arKy Na:760W 0eQ5-7-C91
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not be complered if the permit is for one hundred dollars (5100)
.
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 manmr so as to become subject to the Wimimrs' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT.. if, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Coda you must
forthwith comply with such provisions or this permit shall be deemed smoked
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for the: performance of
the work for which this permit Isissued (Ser. 3097, Civ. C)
Lenders Name
Lenders Address
1 certify that I have read this application and state that the above Information is
correct. l agree to comply with all city and county ordinances and state laws misting 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, coda and expenses which may in any way scenic against said City
in consequence of the granting of this permit.
APPLICANTUNDERSTANDSAND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
—
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Re -roofs
—
Type of Roof
Signature of A licam tractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant stare or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code. zss32(a)T
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[:]yes
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
Will the applicant or future building occupant use equipment Or devices which
emit hazardous air contaminna as defined by the Bay Area Air Quality Management
all new materials for inspection.
DWrictT
❑Yes
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Section 25505.25533 and 25534.1 understand that if the building
does not currently have a tenant that it is my responsibility to notify the occupant of the
=u n hich mem he met prior to issuance of a Certificate of
Signature of Applicant Date
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All roof coverings to be Class nt ., or better
Dam '
Owner or�orvrd agent