09020048BUILDING DIVISION PEMM
OWNER'S NAME:
ARCHI ECT/ENGTNEFR:
a p p LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) olDivision 3 of the Business as Code and my license is
13
in laacz and effect J'-z'Lk. t
Dater Contractor H
i ARCHITECTS DECLfRATIOR
# I understand my plant shill be used as public records
Ca
(.icrnsed Professional
y OWNER -BUILDER DECLARATION
I hereby &ITrm that 1 am exempt from the Contractors license Law for the
00 following mason. (Section 7031.5, Business and Professions Code: Any city or county
$ 9 which requires a permit to construct, alter, hnptove, demolish, or repair any structure
z 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 Contractors L icerm Law (Chapter 9
F (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 arty applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5.500).
0 L as owner or the property, or my employees with wages as their sole compensation,
will do the work. and the structure is riot intended or offered for sale (Sec. 7044, Business
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
oven employers, provided that such improvements are not hueoded or offered for safe. 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.}
❑ L as owner or the property, am exclusively contracting with Wznaed contractors to
construct the project (Sex. 7044. Business and Professions Code:) The Contractors Ll -
muse 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 Sex , B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one or the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Workres Cornpen-
sadon, as provided for by Section 3700 of the labor Com. for the performance of the
work for which this permit is issued.
a I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance or the work for which this permit is issued.
My Workers Can on Insun cc carrier and Policy
number ate: t
Cariier�0.�_ (A^RrKQ� U
Policy No_ _���`��lV<
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Crhis section need not be completed Lithe permit is for oac hundred doll= (S 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 or California Due
Applicant
NOTICE TO APPLICANT. IL after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
.J O forthwith comply with such provisions or this permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
I hereby afrrm that there is a construction lending agency for the performance of
C4 > the work for which this permit is issued (Soc. 3097, Civ. C)
QLanders Name
Lenders Address
V Q I certify that I have read this application and state that the above information is
LT. correct. I agree to comply with all city and county ordinances and stale laws relating to
Q V building construction. and hereby authorise representatives or this city to enter upon the
W above-mrnOoncd party for inspection purposci
a (We) agree to save, indemnify and keep harmless the City or Cupertino against
H to liabilities, judgments, costs and expenses which may in any way scenic against said City
(;,,) `7 in consequence or the granting or this permit.
rte- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
souR/
S
SigatureolApp icbtlConractorf Q
ate
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hsardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code. Section 25532(a)7
❑ Yes 8 No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as dcOncd by the Bay Area Air Quality Management
District?
0 Yes til No
I have read the baardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sacha 25505.25533 and 25534.1 understood! thxilthc building
don not currently have a imam, that It is my resporaibilitytonotify the oau{wn o! tip
equ;mmco which must 6e metp�orm of 11 Certificate 11L6 q
3
Owner or authorimtdOweer or agent Date
PERMIT NO,
PERMIT ISSUE DATE
S CONTROL NO.
BURRING PERMITINFO
BLDG ELECT PLUMB
Job Description
INSTL 2.4 KW PHOTOVOLTAIC ARRAY
Ft. Floor Area
on
APN Number Occupancy Type
32616027.00
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date 7—/2-0__'
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'%q" or better