09080059 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 903 BROOKGROVE LN CONTRACTOR:DURA-FOAM,INC PERMIT NO:09080059
r)�"" `;R'S NAME: SMITH FRANK M AND MADELYN R S 1185 O'BRIEN DR DATE ISSUED:09/01/2009
ty R'S PHONE: 4082579542 MENLO PARK,CA 94025 PHONE NO:(650)327-3200
❑ LICENSED CONTRACTOR'S DECLARATIO BUILDING PERMIT INFO: BLDG ELECT/ PLUMB
License Class Lie.#
� MECH � RESIDENTIAL� COMMERCIAL
-���Contract gc Gt? � Date
I hereby affirm that I am licensed under the provisi of Chapte 9
JOB DESCRIPTION:PHOTOVOLTAIC INSTALLATION
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I 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 Sq.Ft Floor Area: Valuation:$24000
performance of the work for which this permit is issued.
I 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 APN Number:37539023.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that 1 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 enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the o-- �' -
granting of this permit. Additionally,the applicant understands and will comply Issued ky-1- Date:
with all non- int source regulations per the Cupertino Municipal Code ection
9.18.
Signature �. Date f
RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
❑ OWNER-BUILDER DECLARATION installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: Signature of Applicant: Date:
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). HAZARDOUS MATERIALS DISCLOSURE
1 hereby affirm under penalty of perjury one of the following three I have read the hazardous materials requirements under Chapter 6.95 of the
declarations: California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain a Certificate of Consent to self-insure for Worker's compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Compensation,as provided for by Section 3700 of the Labor Code,for the Safety Code,Section 25532(a)should I store or handle hazardous material.
performance of the work for which this permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I have and will maintain Worker's Compensation Insurance,as provided for by contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Section 3700 of the Labor Code,for the performance of the work for which this Health&Safety Code,Sections 25505,25533,and 55 4.
permit is issued.
I certify that in the performance of the work for which this permit is issued,I shallor authorized age
Ow P�
not employ any person in any manner so as to become subject to the Worker's Date:
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must CONSTRUCTION LENDING AGENCY
forthwith comply with such provisions or this permit shall be deemed revoked. I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued(Sec.3097,Civ C.)
APPLICANT CERTIFICATION Lender's Name
I certify that I 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 Lender's Address
to building construction,and hereby authorize representatives of this city to enter
ur. 'he above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
►i, ;fy and keep harmless the City of Cupertino against liabilities,judgments,
cos .,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
gra.►ting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date