09070143 REV1 F CUPERTINO BUILDING PERMIT
CITY o PERMIT NO:09070143
CONTRACTOR:COBALT POWER
BUILDING ADDRESS: 22001 L1NDY LN SYSTEMS,INC DATE ISSUED:07/30/2009
2444 OLD MIDDLEFIELD WAY STE F
OWNER'S NAME: TOM&HEMAL SURRETTE PHONE NO:(650)938-9574
MOUNTAIN VIEW,CA 94043
p, ;;R'S PHONE: 4088051360 ECT PLUMB
BUILDING PERMIT INFO: BLDG EL
13 LICENSE CONTRACTOR'S DECLARATION COMMERCIAL
Class � MECH RESIDENTIAL
License
lA Date � y OB DESCRIPTION:INSTALL ROOF MOUNTED PHOTOVOLTAIC SYS
Contractor � � J
BATTERY
I hereby a irm th am 1' used under the provisions o the Business&Chapter Professions BACK-UP) CTURAL ROOF
(commencing with Sections On ful force vision nd effect. 11/04/09 REVISION#I-REVISE STRU
Code and that my license
I hereby affirm under penalty of perjury one of the following two declarations: -�-VIS'O
I have and will maintain a certificate of consent to self-insure deVfrker's
Compensation,as provided for by Section 3700 of the Labor Co
the r
performance of the work for which this permit is
issued. eas provided for by
I have and will maintain Worker's Comp , Valuation:$91738
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area:
permit is issued.
Occupancy Type:
APPLICANT CERTIFICATION APN Number:35627002.00
I certifythat I have read this application and state dinar ethe s and stave te laws relating
with ation is
all city and county o
correct.I agree to complycity to
to building construction,and hereby authorize representatives of this agree to save WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We) aveIT EXPIRES IF ISS
OR
d keep harmless the City of Cupertino against liabilities,
judgments,of the PERM DAY
OF PERMIT I
indemnify anp in consequenceWITHIN 180 DA
costs,and expenses which may accrue heains 1 cant understands and will comply
Additionally,the app n YS FROM LAST CALLED INSPECTION.
granting of this permit. A per the Cupertino Municipal Code,Sectio 180 DA
with all non-point source regulations
9.18. Date:
� � Date z
y�- 1 �-' Issued b�
Signature
0 OWNBUILDER DECLARATION
ER- RE-ROOFS:
roofs shall be inspected prior to any roofing material being installed.If a roof is
hereby affirm that I am exempt from the Contractor's License Law for one of All I agree to remove all new materials for
I he y
the following two reasons: ees with wages as their sole compensation, installed without first obtaining an inspection,
I,as owner of the property,or my employ inspection.
isnot intended or offered for sale(Sec.7044, Date:
will do the work,and the structure
Signature of Applicant:
tracting
Business&Professions Code) with licensed contractors to
I,as owner of the property,am exclusively con
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations: Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate o on 3700 of the Labor Code,for the 5533 and 25534. I will maintain
t I have read the hazardous materials requirements2 under Chapter 6.95 oft e
Compensation,as provided for by Sec Code,Sections 25505,
California Health&Safety Chapter 9.12 and the Health&
performance of the work for which this permit is issued. rovided for by compliance with the Cupertino Municipal Code,
for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's r t Compensation nce of the,as work S h' or devices which emit hazardous air
Section 3700 of the Labor Code,for the p Additionally,should I use yequipment the Bay Area Air Quality Management District I will
permit is issued. Chapter 9.12 and the
of the work for which this permit is issued,I�shall contaminants
compliance wt h the Cupertino Municipal Code,
I certify that in the performance maint P
not employ any person in any manner so as to become subject to the Workers Health&Safety Code,Sections 25505,25533,and 2553 .
Compensation laws of California. If,after making this certificate of o Code,I must orized hge
pOwner or
become subject to the Worker's Compensation provisions oDate: ✓ .
forthwith comply with such provisions or this permit shall be deemed revoked.
ION CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
the above information is enc for the performance of work's
at I have read this application and state d state laws relating I hereby affirm that there is a construction lending agency
I certify that ordinances an
agree to comply with all city and county f this city to enter for which this permit is issued(Sec.3097,Civ C.
correct.I ag Lender's Name
to building construction,and hereby authorize representatives o agree to save
for inspection purposes.(We)
ups--the above mentioned property menu,
ii ify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
accrue against said City in consequence of the
coy...,and expenses which may applicant understands and will comply
granting of this permit.Additionally,the appCu ertino Municipal Code,Section ARCHITECT'S DECLARATION
with all non-point source regulations per the p I understand my plans shall be used as public records.
9.18. �
Date Licensed Professional
Signatur