09030215CITY OF CUPERTINO
PERMIT
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BUILDING DIVISION
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BUILDING ADDRESS:
PERMIT NO.
21350 VAI AVE
COBALT POWER SYSTEMS INC
09030215
OWNER'S NAME:
PERMIT ISSUE DATE
DA IT1) fY STFPHANTA KANE
PHONE:c,
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A A O. CONTROL NO.
(650) 938-9574
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3ofthe Business and Professions Code.and mylicense is
in fun and e[fecl� -7
INSTALL ROOF MOUNTED PHOTOVOLTAIC SYSTEM (SOLAR
O x �.� O� g
License Cl
Date Contractor
Dale Contractor
PANELS) NO BATTERY BACKUP.
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 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter. improve, demolish, or repair any structure
Sq. Ft. Floor Area
Valuation
prior to its issuance, also requires the applicant for such permit to file a signed statement
Law 9
that he is licensed pursuant to the provisions of the Contractor's License (Chapter
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$38890
that he is exempt therefrom 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 five hundred dollars (5500).
36205029.00
❑ I, as owner of the property. or my employees with wages as their sole compensation,
nss
Required Inspections
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will do the work, and the structure is not intended or offered for salt (Sec. 7044, Business
and Professions Code: The ContractorLicense 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 sal& lf,
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 (Sec. 7044, Business and Professions 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 to the Contractors
License Law.
❑ 1 am exempt under See B & P C for this reason
'owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate or consent to uhf -insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Carrier @jbZg2- r n n l'l rm/r4 Iicy Nn: 7&V0Q0o0 7 -sl
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be 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 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
forthwith comply with such provisions or this permit shall be deemed revoked.
' CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lenders Address
I 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 relating to
~ building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes
4 (We) agree to save, indemnify and keep harmless the City of Cupertino against
r) liabilities, judgments, costs and expenses which may in any way accrue against said City
r in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND ILL COMPLY WITH ALL NON -POINT
Issued b3: Date
SOURMRLATIONS.
-710
Re -roofs
T of Roof
Type
Signature Applicani/Contracor I D
MATERIALS DISCLOSURE
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(a)?
❑ Yes
All roofs shall be inspected prior to any roofing material being installed.
tP4
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 contaminants as recd by the Bay Area Air Quality Management
all new r iaterials for inspection.
District?
❑Yes u
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Cade, Sections 25505, 25533 and 25534.1 understand that if the building
does not currently have a tenant, that at responsibility to notify the occupant of the
' Certificate oreap�tc
Date
rcquimmcnts h must be mel prior uartco of a of
'
Signature. of Applicant
All roof coverings to be Class ' j ' or better
Owner or authorized agent