07100205 CTTY OF CUPERTINO ` ' ''
BUILDING DIVISION pERMIT ���� ������������ '
: '; :.; > , , ; _ ,. .. _ ..
BUILDING ADDRESS: PERMIT NO.
21123 GRENOLA DR REC SOI�AR 07100205 .
JER'S NAME: � �� DA �
EMBRY WESLEY 684 CL��RION CT 11/07/2007
PHONE: SANiTARY NO. CON'IROL NO.
ARCHI'IECT/ENGINEER: BU[LDtNG PERMIT INFO
SOLAR :�YSTEM MOUNTED ON THE B� ED p�� 0
u o p LICENSED CONTRAC7'OR'S DECLARATION !
� 1 Mrcby �rm Uw� I am licenscd umicr provisians o[ Chaptcr 9(commencing Job Description
� V � with SccGon �000) of Division 3 of Ihc Husincss and Profcssions Codc. and my licensc is
"� y in full Corce and effea. �- S a � 8 y
n � Z Licenac Class � L�. +�
F p p'� Conuac�ar 6L S� �
�',� � ` ARCHI7EC1'S DECLARATION
� � I undcrstand my plans shall bc uscd u public rccords
m�
a
U
L O y Liccnscd Rufcssional
n y � OWNER-BUILDER DECLARATION
I hercby alTrm Ihat I am cxcmpt from the Conuactars Liccnsc Law for tlic
� p O following rcason. (Scction 7031.5, Busincss and Profcssions Caic: Any city or county
K, Pi which rcquims a permit w conswc4 a��*. �provc, dcmolixh, or �cpair any swcwrc
y Z � prior to i�s issuancc, also mquims ihc applicam for such pertnit to filc a signcd s�a�emen� �,
_< that he is liccnxd pu[suanl ta lhc provisions of thc Conuactur's Liccnsc Law (Chaptcr 9 ,�q. Ft. Floor Area Valuation
y t- $(commcnring wi�h Scction 7000) of Division 3 of Ihc Businr.cs and Profcssions Cadc) or
y �.. that he is exempt theeefrom �nd ihe basia (or the ailegcd exempdon. Any violaGan of
SecGon 7031.5 by a�ry applicant (or a pem�it subjecu ihe applicant to s civi! penal�y of APN Number Oeeupaney Type
not more than fiw 6undmd dollars (5500).
❑ I, u owner o[ the properey. or my wployces with wages u their sole campensation,
will do �he work, end the stiucwee is not imm�ded or affeced for sale (Sec. 7044. Business Re uired Ins ections
and Ro[essions Cade: The Conuutor's License Law docs not apply to an owner of q p
pcaperty wha builds or improvu therean, and who das such work himsel[ or Uvough his
own employces, provided that such improvemen�s ue not in�ended or ofkred for sale. I[,
however, the buildinp or impmvement is sold wilhin ont year of completion, ihe owner-
builder will have the burden of proving �Aat he did noi build or improvc [or purposo o(
sale.).
0 1, as awner of ihe property, am exclusively conuacting wi�h Iicensed rnnuactors w
conswct the pmjea (Sec. 7044. Business and ProCessions Cade:) The Coauacwr's Li-
cenae Caw docs not apply to an owner of propeny who builds or improves Iheceon, and ,
who convac�s tor sucfi projecu wi�h a conuactar(s) ticensed pursuant to the Coniruror's
Licenae I.aw.
r'7 I am ezempt under Sec. , B de P C far this rcawn
nu Date
WORKER'S COMPENSA'I70N DECLARATTON
I hereby �rm under penalry of perjury one o[ �he follawing declarotions:
❑ 1 hsve and will mainuin a Cenificate of Conunt w self-inswe (or Workers Compen-
sation, u providcd for by Secuon 3700 at the Laboc Code, far �he pe6ormance of �he
work for which this prrtnit is issucd
❑ I have and will maintain Worker's Compensation Insunna. as �cquired by Scction
3700 oC the Labor Codc, Cor thc pedormance of �he work for which this peimit is istued
My Wor s Com nsaGon Insunnce csrticr and Poliry bcr arc:
�em�: �(a��o t�a� ��;�, No.: o 11 .�3� � 3
CERfIF7CATE OF EXEINPTION FROM WORKERS'
COMPENSATIONINSURANCE '
(77iis sectirni necd not be complctcd if the pertnit is fw o� hundrcd doiiars (5100)
or Icu) '
I cenify lhnt in thc performance of the work for which Ihis pertnit is issued. [ shall not
employ any person in any manncr w az m becomc subject to the Workcrs' Compensation
Laws of Califomia. Da�c
Applicam
NOTiCE TO APPLICANT: If, aMr making ihis Ccrtificaic of Exemption, you should
become subject w ihe Worker's Compensation provisions of thc Lslwr Codc, you must
� O forthwith comply wi�h such provisions or this pecmit shall be deemed revoked.
z "'' CONSfRUC1'ION LENDING AGENCY
F r � I hcrc6y a�rm Uu� thcre is a conswction Icnding agency Cor Ure perCormancc uf
(Si � ihc wurk for which ihis permi� is issucd (Scc. 3097, Civ. CJ
W� A L.ender's Name '
� z Lender's Address
V 0 � certifY �hrt 1 have rcad ihis applicuion and stalc that thc above info�matiun is
w ►' cortect I agrce a comply wi�h all ciry and county ontinantts and sute Iaws telaiing w
0 U building consuuction, and hcreby wthorix represcntativcs of ihis city to cn�cr upon �hc
� W above-mcndoned pmpcny fm inspection purposes.
a (Wc) agtee to save, indcmnify and keep humless ihe Cily of Cupertino against
�� liabilitiu, judgmcn�s, cos�s and expcnscs which may in any way accruc againsl said City
V`� in consequence of Ihc granting of ihis permi� Date
►°� APPLICA111' UN RS'fA AND W L COMPLY WITH ALL NON-POINT Issued by:
SOURCE I At
1 l` �� �� Re-roofs
�gnuu npplican vsctor �8� Type of R��of
- AZARDOUS MATERIA(.S DISCLOSURE
�1! Ihc pplicant or fuwre building occupant store or handlc ha•rardous matcrial
defincd by the Cupertino Municipal Code. Chapicr 9.12, and the Hcallh and SaCc�y
�. Scction 25532(a)? All roofs : hall be inspected prior to any roofing material being installed.
oY� �o
wll thc applicant or future building occupant usc cyuipmcnt or dcvices which
If a roof is installed without first obtaining an inspection, I agree to remove
emi� ha air conuminan�s u dcfincd by the Bay Ares Air Quality Managcment all new m; �terials for inspection.
District?
❑ Ya ��
1 havc mad the Iwardous maicrials rcquimmenu undcr Chap�cr 6.95 of ihe Califor-
nia Hcal�h & Safcty Codc, Scc�ions 25505, 25533 a�125534.1 undcrs�vid ihu iCU�c building
ciocs rwt curtcnll hayc a �cnan4 lhat it is my nsibili�y w notiCy the occupant nf the
requiremcn h mu;I W i of a Ccrtifica�c of Occu �r. Signature ��f Applicant Date
_-� f ._ � ��1
' �"' � �� All roof coverings to be Class "B" ar better
- �wncr ocTuiharizcd l Da�c '