10100137 (2) CITY OF CUPER'TINO BUILDING PERMIT
BUILDING ADDREss: 10152 CAMINO VISTA DR CONTRACTOR:COBALT POWER PERMIT NO: 10100137
SYSTEMS, INC
OWNER'S NAME: ANTHONY HURTADO 885 MAUDE AVE DATE ISSUED: 10/27/2010
OWNER'S PRONE: 4087684856 MOUNTAIN VIEW,CA 94043 PHONE NO:(650)938-9574
❑ LICENSED CONTRACT 'S DECLARATION F—
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lie.N q JF— r
` nI � � MECI1 RESIDENTIAL COMMERCIAL
Contractor IVJ C/
L 6 JOB DESCRIPTION: INSTALL ROOF MOUNTED PHOTOVOLTAIC SYSTEM 33
1 hereby affirm that 1 am licensed undo the provisions f Ch pier 9 PANELS
(commencing with Section 7000)of Division 3 of the Business& Profession s
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
1 have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$47704
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code, for the performance of the work for which thi: APN Number:34214060.00 Occupancy Typc:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to emer
upon the above mentioned property for inspection purposes. (We)agree to say. 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgmen s,
costs,and expenses which may accrue against said City in consequence of the
granting of this relit. Additionally,theapplicant understands and will comply issued by: Date:
with all non-p urce regulations er Cupertino Municipal Code,Secticn
9.18.
/ RE-ROOFS:
Signat re to �� l 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.
❑ OWN R- UILDE")ECLAJALrI
Signature of Applicant: Date:
1 hereby affirm tha am exempt from the Contractor's License Law for ne of
the following two asons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETrER
1,as owner of the property,or my employees with wages as their sole contpew ation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contracto-s to HAZARDOUS MA"I'ERIALS DISCLOSURE
construct the project(Sec.7044,Business& Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: I lealth&Safety Code,Section 25532(x)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, hapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for b the Health&Safety Code,Sec ' 31--amd 25 /,
Section 3700 of the Labor Code,for the performance of the work for which th s Date: V Z G
Owner or authorized age t:
permit is issued.
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 Worker's
Compensation laws of California. If,after making this certificate ofexemptio i,I CONS"fl UC"1 ION ENllIN'G AGENCY
,
become subject to the Worker's Compensation provisions of the Labor Code, must I hereby affirm that there is a c nstructio lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked work's for which this permit is issued(S .3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have read this application and state that the above information i;
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 et ter
upon the above mentioned property for inspection purposes.(We)agree to saN a ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities.judgme its.
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the ap ica understands and will comply
with all non-p cc regulations per le lino Municipal Code,Section Licensed Professional_
9.18.
Signa re Date /D V U