09050142 CITE'OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO.
1179 STAFFORDER :N—DEAN_
OWNER'S NAME: PERMIT ISSUE DATE
"O
_ NT RiSE BR A CONTROL NO.
(510) 494-9982
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u o p LICENSED CONTRACTOR'S DECLARATION
m I herebyaffirm that I am licensed under provisions of Chapter 9(commencing Job Description
v with Section 7000)of Division 3 of the Business and Prof C ,and my license is
� y in full force andftect RF MOUf1TD PHOTOVOLTAIC SYS, RESIDENTIAL
Z License C ►
n f O Datc Contractorf)LIT
ARCHITECTS DEC N
4 5< I understand my plain shall be used as pub rc records
YrJ
O H Licensed Professional
n y 3 OWNER-BUILDER DECLARATION
2<2 I hereby affirm that I am exempt from the Contractor's License Law for the
is p O following mason.(Section 7031.5,Business and Professions Code:Any city or county
,4 m Pi which requires a permit to construct.alter•improve,demolish,or repair any structure
4;- prior to its issuance,also requires the applicant for such permit to rile a signed statement
F G that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of 0
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars($500).
0 I,as owner of the property,use my employees with wages as their sole compensation. 3 62 110,:3 . 00
will do the work,and the structure is not intended or offered for sale(See.7044,Business
and Professions Code:The Conuacto's License Law does not apply to an owner of Required Inspections
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 of
sale.).
0 I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's U.
cease Law does not apply to an owner of property who builds or improves thereon,and•
who contracts for such projects with a contractors)licensed pursuant to the Contractofs
License Law.
0 I am exempt under See. B&P C for this mason
OwnerLADate
WORKER'S COMPENSATION DECRATION
I hereby affirm under penalty of perjury one of the following declarations:
0 1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
0 I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Codc,for the performance of the work for which this permit is issued.
My Worker/s�C/g/�tlpensation lrtsu pc�a.rrier and Polity number cera: /L
Cartier. _'-CLC VW 17i R Polity No.: 7(y_G jZ
CERTIFICATE OF EXEMP ION 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
Oforthwith comply with such provisions or this permit shall be deemed mvokcd.
z" CONSTRUCTION LENDING AGENCY
E.r mQf]-r 1 hereby affirm that there is a concoction lending agency for the performance of
(x the work for which this permit is issued(Sec.3097.Civ.C.)
WW A Lender's Name
Z Lender's Address
V 0 I certify that I have read this application and state that the above information is
VL►" correct.l agree to comply with all city and county ordinances and state laws relating to
C V building construction,and hereby authorize representatives of this city to enter upon the
W be El p perry for inspc on
purposes
(Wc)agree o save,indcm' and keep harmless the City of Cupertino against
Iiabilitiex,judgmc ts,costs and a which may in anyway accrue against said City
V Z in consequence o the gNEI
o is permit.
►. APPLICA U DERSTA NO WILL COMPLY WITH ALL/ON-PINT Issued by: Date `
DISCLOSURE Type Of Roof
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
Code,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes �No
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new IT aterials for inspection.
District?
0Yes PNu
Ihave n6d thehazardc materials requirements under Chapter 6.95ofthe Califor-
nia Health&
Date