09030003BUILDING DIVISION PERMIT
OWNER'S NAME:
ARCHITECT/ENGINEM-
u C Zp LICENSED CONTRACTOR'S DECLARATION
IU t hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Mwith Sccdon 7000) of Division 3 of the Business and Profession Code. and my Tice, is
in full force and (-Y6 66 Si3 ' ^ C 3 b ate. s
License -
o Date Contractor
3 ARCHITECTS DECLARATION
t understand my plans shall be used as public records
# u. Licensed professional
} O OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
%o O following reason. (Section 7031.5, Business and Professions Code: Any City or county
.439 9 which requires a permit to construct, alter, improve, demolish, or repair any structure
y y prior to its issuance, also requires the applicant for such permit to Ole a signed statement
3 < that he is licensed Pursuant to the provisions of the Conuactors License Law (Chapter 9
$(commenting 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 arty applicant for a permit subjects the applicant to a civil pertalty of
not more than five hundred dollars (S500).
❑ L as owner of the property. or my aaplayees with wages as their sole compensation,
will do the work and the structure Is not intended a offered for sale (Sec 7041, Buairutss
and Professions Code: The Contractors 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 riot Geld Or Improve for purpose of
sale.).
❑ L as owner of the property. am exclusively contracting with licensed contractors to
connruct the project (Sec. 7044. Business and Professions Code:) The Contractor's LI-
cease 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.
❑ I am exempt under Sec , B & P C for this reason
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ t have and will maintain a Ceniliale of Consent to self -insure for Workcrs Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
-TTave and will maintain Workers Compensation insurance, as required by Section
(This section need not he 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 shaft not
employ any person in any manner so as to become subject to the Worked 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 Code, you must
,J z forthwith comply with such provisions or this permit shall be (iccmcd revoked.
z O CONSTRUCTION LENDING AGENCY
[� I hereby affirm that there is a construction lending agency for the performance of
�i > the work for which this permit is issued (Sec. 3097, Civ. C.)
W 0 Lenders Name
Z L.endces Address
f,,,) 0 1 certify that 1 have read this application and state that the above information is
LT.. f".,".,' certeeL 1 erg= to comply with all City and county. ordinances and state laws relating to
C) y building construction, and hereby authorize representatives of this city to enter upon the
W above -mentioned property for Inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
V2 liabilities, Judgments, costa and expenses which may in any way accrue against said City
V 7 In consequence of the granting of this permlL
►7 APPLICANT UNDERSTA S AND WILL COMPLY WITH ALL NON -POINT
Date
HAZARDOUS MATERIALS DISCLOSURE
WIB the applicant or forum building eccupantatom of handle hanrdous material
as deOned by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code. Section 25532(a)7
[ Yes 68—
WW the applicant or future building occupant use equipment or devices which
emit haiardous air contaminants as dclined by the Bay Area Air Quality Management
Oisuict7
Cl Yes
1 have mad the luuardous materials requirements under Chapter 6.95 of the Califor-
rux Health & Safely Code, Sections 25505, 25533 and 25534.1 understand that if the building
does rat currently haw a tcnarht, tut it' my responsibility to ratify the accupantp/of the
a CertiLalc offief,
Owner a authorvsnl agent Date
408)927-08
PERMIT NO.
PERMIT ISSUE DATE
e e 9
At?A Itt
CONTROL NO.
BURNING PERMIT INFO
BL.DG
ELECT PLUMB MECH
Job Description
INSTL FLUSH -MOUNT PV SYS ON RES ROOF
Sq. Ft. Floor Area
737
Valuation
APN Number Occupancy Type
35603024.00
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date ' �- ( f --b 5
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'%" or better