09020097 CITY OF CUPERTINO PERMIT
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS:
20937 FAIRWOODS CT HORIZONpERMITLSSUEDATE
11"NER'S NAME:
jT7�AN C8.2
AM11PEaFT�T� r crnmm nv�o p CONTROL NO.
PHONE:
(408) 39E -9060 BUILDING PERMIT INFO
ARCHITECTJENGINEER: BLDG ELECT PLUMB MECH
0 0
,,c c LICENSED CONTRACTOR'S DECLARATION Job Description
U I hereby affirm that I am licensed under provisions oC Chapter 9(commencing
_z with Section 7000)ofDivision3ofdtcBusirtess Profcss'ionsCode.andmGyylicenscis INSTL SOLAR PHOTOVOLTAIC GRID-TIE SYS, .FLUSH
y in full force and (7 Lic.N __` `
v�z License Claw Contractor s , NTD,
t- Dam /
e pRCHCTECTSDEC RATION NO BATTI RIES
# 5, 1 understand my plans shall be used as public records
5yU
L u.rF„ Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
alter.improve,demolish,or repair any structure
which requires a permit to construct Valuation
prior to its issuance.also regains the applicant for such permit to file a signed statement 3 Ft.Floor Area
^e that he is licensed pursuant to the provisions of the Conuacmr's License Caw(Chapter 9 Cl
F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
110 that he is exempt themfrom and the basis for the alleged exemption.Any violation of APN Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars MIX 3 5 91311 L . 00
❑1.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.It,
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 Contractor's Li-
cense Caw does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a conuactor(s)licensed pursuant to the Contractor's
License L-w• ,B&P C for this reason
❑I am exempt under Sec
-
Dare —F
nee
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for workres compen-
sation,as provided for by Section 3700 of the Labor Code.for the performance of the
e
which this permit is issued.
and will maintain Worker's Compensation Insurance,as required by Section
he Labor Code,for the performance of the work for which this permit is issued.
My Workee. Corypeasa�tion�lnsurapp carrier and Policy number arc:
Cartier. g-` 4?
oliry,No.:7 13^O
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less)
1 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 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
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
Z R CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
a, the work for which this permit is issued(Sec.3097,Civ.C.)
W ALendces Name
]Z Lender's Address
I certify that 1 have read this application and state that the above information is
LUL coI l agree to comply with all city and county ordinances and state laws relating to
Q U building convection,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes
>"t nWi (We)agree to save,indemnify and keep harmless the City of Cupertino against
tE'"t liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit. Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH L NON-POINT Issued by:
SOURCE ATIONS. el VIr..Z_
Re-roof:
Signature of Applianucontractor 1111.0 Date T of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
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
^ode,Section 25532(x)9 All roof 3 shall be inspected prior to any roofing material being installed.
❑Yes IN. If a root 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 materials for inspection.
District?
❑Yes o
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently.have a tenant,that it is my resPonsibility otiry the occupant or the Date
require h must tic to iss w of of oCC11pa" Signature Of Applicant
All roof coverings to be Classor better
Owner or authorized agcnl Date