090601637� C
a V
UC
wF
O�
�a
U2
CM OF CUPERTINO
Ik:
BUILDING DIVISION PERMIT
.... .,
BUILDING ADDRESS:
PERMIT NO.
20960 GARDEN GATE DR
REGRID POWER
09060163
"INER'
CONTROL NO.
(408)927-0811
ARCHn=/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of tt Business and Professions Code, and my license is
INSTL ROOF -MOUNTED PV ( SOLAR) ON ROOF
in full force and ecL
'scenes CI LRc. s
Data Contractor
ARCHITECTS DFLLARA N
1 understand my plans shall be used as public records
Licemsed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's Ucense Law for the
following mason. (Section 70313, Business and Professions Code: Any city or county
which requires a permit to congruct. alter, improve, demolish, fir repair any structure
prior to its issuance. also requires the applicant ror such permit to rile a signed sttemcot
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the Conractors License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Proressioea Code) or
2 4 219
that he is exempt therefrom and the basis for the alleged exemption Any violation of
APN Number
Occupancy Type
Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars 45M.
32630015 .00
❑ L as owner of the property, or my employees with wages as their sole compensadon,
Required Inspections
will do the work, and the sbuctum is not intended or offered for sale (Sec.7044, Business
and Proremlons Code: The Conuactor's Lkense Law dart not appi to an owner or
property who builds or improves thereon, and who does such work himself at through his
own employee, provided that such improvement are act intended or offered for sale. If,
however, the building or improvement is sold within one year or completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose or
sale.).
❑ I. as owner or the property, am exclusively contracting with licensed contractors to
construct the project (Sec.1044, Business and Professions Code:) The contractors u-
cense Law does not apply to an owner of property who builds or improves thereon, and.
who contract for such projects with } conwctor(s) Bcen ci pursuant to the Contractors
License Law.
❑ 1 am exempt under Sec , B & P C for this mason
rtu Date
WORKER'S COMPENSATION DECLARATION
i hereby affirm under penalty of perjury one of the following declarations:
❑ I haw and will maintain a Certificate of Consent to self -Insure for WorkeesCompen-
.
salon, 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 Worker's Compensation lamnna, as required by Section
3700 of the labor Code, for the performance of the work for which this permit IS issued.
'
My Worker's Compensation insurance carrier and Policy number are:
Carrier. A21 l t � 7/ C- Polley No.: b
E�iFiCATE OF EXEMPTION FROMWORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit Is for one hundred dollars (S 100)
or less.)
I certify that in the perfarmancc of the work ror which this permit is issued, I shall not
employ any person in any maancrso as to become subject to the Workers Compe radon
Laws of California Date
Applicant
NOTICE TO APPLICANT: If, alter 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 fir This permit shall he 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. 309r7, Civ. C.)
L.ondees Narna
,
Lenders Addicts
I certify that i have read this application and seta that the above information is
correct I 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.
(We) agree to save- indemnify and keep harmless the City of Cupertino against
liabilities. Judgment, case and expenses which may In any way accrue against said City
A
MATERIALS DISCLOSURE
Will the applicant or future building occupant sore orhandle h— ous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
25532(a)?
Wc, Section -I
All roofs shall be inspected prior to any roofing material being installed.
Yes ❑No
❑Yes
If a roof is installed without first obtaining an inspection, I agree to remove
Will the a licant fir futum building ore
pp g pant use equipment fir devices which
emit hazardous air contaminant as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes ONO
i have mad the haurdaus materials requirement under Chapter 6.95 of the Cali for.
nia Heal lh & Safety Cade, Sections 25505.25533 and 25534.1 understand that U the building
does not currently have