08120115Q
CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PERMIT NO.
6354 BLACKWOOD DR
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OWNER'S NAME:
PERMIT ISSUE DATE
S CONTROL NO.
ARCHITBCT/ENGiNEER:
BUILDING PERMIT INFO
4.5 KW ROOF FLSH MNTD
BLDG ELECT PLUMB MECH
O O D O
LICENSED CON7RACTOWSDECLARA770N
PHOTOVOLTAIC SYSTEM �6t�l3 cription
1 beroby affirm that I am licensed under provisions or Chapter 9 (commencing
with Section 700M or Division 3 or the Business and Profess!= Code, and my license fa
in cull face and effect
Lleeme Class C-.10 LIC. rr `a>a5i oy
,
Date O g 1410q Cont act. A
— ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 70315, Business and Professions Code: Any city or county
which requires a permit to construct. after. improve. demolish, or repair any structure
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 provisions of the Contractor's LJcensc Law (Chapter 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 exempdon Any violation of
APN Number
Occupancy e
cY TYP
Section 70315 by arty applicant for a permit subjects the applicant to a civil penalty of
t:
not mothan five hundred dollars (SM
P
❑ I, as owner of the property, or my employees with wages as their sole compensation,
e
Required cellons
will do the work. and the met= is not intended oroffered for tale (Sec.7044,Business
and Profusions Code: The Contractor's License Law does not apply m an owner or
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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 or
sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (See. 7044. Business and Professions Code:) The Comra=es L-
cwe Law docs not apply to an owner or property who builds or improves themon, and ,
who contracts for such projects with a contramo(s) licensed pursuant to the Contractor's
C.leeuse 4w.
❑ 1 am exempt under Sec . B & P C for this reason
Owner Due
WORKER'S COMPENSATION DECLARATION
i hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate or Consent to self -insure for Workers Coepen-
sadon, as provided for by Section 3700 or the Labor Code, for the performance of the
work for which this permit is issued.
have and will maintain Workers Compensation insurance, as required by Section
of the Labor Code, for the performance of the work for which this permit is Issued
My Worker s Conpeas on carrier and Polity nuns
Carder�`��
FROM WORKERS'
COMPENSATION INSURANCE
(nit section need not be completed if the permit is ro one hundmd douars WOO)
or less.)
i cenify that to the performance or the work for which this permit is Issued l than no
employ any person in any maoner so as to become subject to the Workers' Compensadon
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions or tiw Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revalue
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a contsuuctinn lending agency for the performance of
the work for which this permit Is issued (Sec. 3097, Civ. C)
llndeesName
Lender's Address
i certify that i have read this application and state that the above Information is
correct 1 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
(Wer) agree to save, indemnify and keep harmless the City or Cupertino against
liabilities, judgments, costs and expenses which may In any way accrue against said City
in consequence of the granting of this permiL
<—,
APPLICANT UNDERSTANDS AND WiLL COMPLY WiTH ALL NON -POINT
Issued by: Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applieantor fat= building acupsatstore or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code, Section 25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
❑Yrs �No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or forum building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Ares Air Quality Management
all new materials for inspection.
District? � J
❑Yes VN.
1 have mad he hazardous nwerials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand that it the building
does not currently have a reriam. that It is my responsibility to notary the occupant or the
req