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09120073 (3) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 1109 MILKY WAY CONTRACTOR:TBD-TO BE PERMIT NO:09120073 DETERMINED OWNER'S NAME: PAUL ROBINSON DATE ISSUED: 12/22/2009 *4ER'S PHONE: 6505955955 PHONE NO: © LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL E]INSTALL ROOFI.OP SOLAR PV SYSTEM**SLE NOTES License Class- C, `(� Lic.#-3,1 Contractor�L 12V C 104- Date_12•-L-L -09 I hereby affirm that 1 am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. Valuation:$21000 Sq.Ft Floor Area: 1 hereby affirm under penalty of perjury one of the following two declarations: r. 1 have and will maintain a certificate of consent to self-insure for Worker's APN Number:36219011.00 Occupancy Type: Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. 2. 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 this PERMIT EXPIRES IF WORK IS NOT STARTED permit is issued. WITHIN 180 DAYS OF PERMIT ISSUANCE OR APPLICANT CERTIFICATION 180 DAYS FROM LAST CALLED INSPECTION. 1 certify that 1 have read this application and state that the above information is correct.1 agree to comply with all city and county ordinances and state laws relating z.v. Date: to building construction,and hereby authorize representatives of this city to enter Issued --- upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the RE-ROOFS: granting of this permit. Additionally,the applicant understands and will comply with All roofs shall be inspected prior to any rooting material being installed. If a roof is all non-point source regulations per the Cupertino Municipal Code,Section 9.18. installed without first obtaining an inspection,1 agree to remove all new materials for Signature Date_�L inspection. LZ!a9 Signature of Applicant: Date: OWNER-BUILDER DECLARATION ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1 hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: t. 1,as owner of the property,or my employees with wages as their sole HAZARDOUS MATERIALS DISCLOSURE compensation,will do the work,and the structure is not intended or offered for 1 have read the hazardous materials requirements under Chapter 6.95 of the sale(Sec.7044,Business&Professions Code) California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain 2. I.as owner of the property,am exclusively contracting with licensed contractors tt compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& construct the project(Sec.7044,Business&Professions Code). Safety Code,Section 25532(a)should 1 store or handle hazardous material. Additionally,should 1 use equipment or devices which emit hazardous air I hereby affirm under penalty of perjury one of the following three declarations contaminants as defined by the Bay Area Air Quality Management District 1 will 1. 1 have and will maintain a Certificate of Consent to self-insure for Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Compensation,as provided for by Section 3700 of the Labor Code,for the Health&Safety Code,Sections 25505,25533,and 25534. performance of the work for which this permit is issued. Owner or authoriz d age 2. 1 have and will maintain Worker's Compensation Insurance,as provided for by _ �.1! � Date. !Z-_2:2-_ Section 3700 of the Labor Code,for the performance of the work for which this pen-nit is issued. CONSTRUCTION LENDING AGENCY 3. 1 certify that in the performance of the work for which this permit is issued,I shall I hereby affirm that there is ad(Sec.3097,Civ C.) construction lending agency for the performance of work's not employ any person in any manner so as to become subject to the Worker Compensation laws of California. If,after making this certificate of exempti's for which this permit is issueon,I — become subject to the Worker's Compensation provisions of the Labor Code,I Lender's Name must forthwith comply with such provisions or this permit shall be deemed Lender's Address revoked. ARCHITECT'S DECLARATION APPLICANT CERTIFICATION I understand my plans shall be used as public records. I certify that 1 have read this application and state that the above information is correct.I agree to comply with all city and county ordinances and state laws relating Licensed Professional 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,judgments, and expenses which may accrue against said City in consequence of the ng of this permit.Additionally,the applicant understands and will comply witf all tion-point source regulations per the Cupertino Municipal Code,Section 9.18. Signature.—*--A Date 0-' Aa`