07110019 CITY OF CUPERTINO <
BUILDING DIVISION PERMIT ���R��.�C?R I���'���1� .'
,. . . ;.:: ;: -::... _ :.,:: .:.
BUILDIN ADDRESS: PERMIT NO.
1�126 LINDA VISTA DR TBD - I'0 BE DETERMINED 07110019 .
v�dNER'S NAME: PERM1T LSSUE DATE
NISSEN JAMES M � 11/15/2007
PHONE: SAMTARY NO. CONTROL NO.
ARCHITECT/EIVGiNEER: BUiLDING PERMIT INFO
ROOF M�UNTED PV B�DC e�cr PLUMB MECH
0 0 0 0
a O p LICENSED CON'IRACTOR'S DECLARATION
� I hcrcby affim� �hat I am licenscd undcr provisions of Chaptcr 9(commcncing Job Description
� z� wiih Scction 7000) of Division 3 of �hc Busincsc and Profcssions Codc, and my licensc is
°� y in full force and eff � D'� /
j� Z Licensc Class ___ c� Lic. M �
y F„ p Da�c 1/—/C Conuacar
� ARCHITECI'S DECLAR
'� I undcrsund my plans shall be u�cd as public rccords
w
o�
4 O y Liccnsed Pn�fcssional
,� 3 OWNER-BUI[.DER DECLARATION
1 hcrcby allirm Uiat 1 am excmpt from thc Contractor's Licensc Law far thc
i p O[ollowing rcason. (Scction 703I.5, Busincss and Profcssians Cadc: Any city or county
K,°, Pi which reyuires s pertnit ta conswct, altcr, improve, dcmalish, or �cpair any stn�cwrc
`� z y priar Io 71s issuancc, also rcquires �hc applicanl for such permit to Glc a signcd stalcmcnt
x < that hc is liccnxd pursuant to uic pmvisions o[ thc Conuacwr's [.i��cnsc [.aw (Chaptcr 9 )q. Ft. FlOOI' AI'C3 Valuation
� t- �(commencing wiih Scction 7000) of Division 3 of ihc Busincss and Profcssions Codc) or
y �.. �hat he ia exempt the�etrom and Ihe buis Cor ihe alicged eumpGon. Any violanon of
Section 7031.5 by a�ry appiicant (or a permit subjecu Urc applican� to a civil penaity of ppN Number Oeeupancy Type
not more ihan fiw hundred dollars (5500).
❑ I, u ow�r of the property. or my employces with wages u theu solc compemadon,
will do the work and ihe s�cuctme is not intended or otfered for sale (Sa. 7044, Business Re uired Ins ections
and Fhofessions Code: 'Rrc Conuacmr's Lianse Law daes not apply w m owner of q p
property w6o builda or improves �heawn, and who das such work himself ar ihmugh his
own employca, provided �hat such improvemen�s ue not inanded or otfeced Cor sale. I[.
however, the building or improvement is sold wi�hin ane year of compledon, ihe owner-
builder will have the burden of p�vving that he did not build or improvc for puryose af
sale.).
� I. as owna o[ the propeny. am exclusivdy conuacting wilh Gcensed convactors W
constnxt the p�njm (Sec. 7044. Busineu and ProCessions Code:) The Convactor's Cd-
ccnse Iaw docs not apply �n an owner of property who builds or improves themon. �nd ,
who convacls Cor such pmjects with a conuactor(s) licensed pursuant w the Convactor's
'-ense Law.
am exempt under Sa. , B� P C for this rcavon
uwner Date
WORKER'S COMPENSATTON DECLARATION
I hereby �cm under penalty of perjury one of the following declaretions:
❑ I ha+e and will mainuin a Cenificam of Consent to sel(-inswe for Workcr's Compen-
sation, u provided (or by Secdon 3700 af the Labor Code, for �he performanu o[ ehe
work t hich this pertnit is issued.
have and will maimain Workers Compensation Insurana, u �cquired by Sccdon
3700 of �he Labor Code. Cor Ihe pedorma�rce o[ Ihe worlc for which this permit is issued
My Workers om e�o n u c� and Poliry num�y�:� _�
LJ
Carticr. Poliry No.: �
CER IFICATE OF EXEMPIiON FROM WORKERS'
COMPENSATION WSURANCE •
(Thu section necd not be comple�cd it the permit is for onc hundced dollua (S 100)
or Icss.) •
I cenify Wai in the performance of thc work for which �his permit is issucd, ! shall na
nmploy any person in any manncr so u to bccome subject w the Worlcccs' Compcnsation
Laws of Cali(omia. Da�c
Applicant
NOTICE TO APPLICAM: If, aflcr making �is CcrtiGca�c of F�ccmption, you shoulJ
bccome subjcct to thc Worlcer's Compensstion provisions af ihc Labor Codc, you must
� O forthwi�6 comply with such provisions or this pecmi� shall bc dccmcd rt.wokcd.
� ""� CONSfRUGTION LENDING F.GENCY
E r.�-� I he�cby a�rm U�at thcre is a consUuctinn Icnding agcncy 1'or thc performancc uf
LY., � ihe wark fur which ihis permit is iuued (Scc. 3097. Civ. CJ '
W� A L.endcr's Namc .
] z (.ender's Address
U O 1 certify �hat I have read this spplication and s�atc that thc abovc infamauun is
w�"� cortcct I ageee to comply wi�h all rity and counry onfinar�cu and su�e Iaws relating w
� U buildins consvuction, and hcreby authoria ceprescn�aGvcs of �his city w cmcr upon thc
W above-menuoncd piopcny far inspectioa purposes
a (We) agree to save, indcmnity and keep harmless ihe City o[ Cupcnino against
�„� � liabilities, gmcnla, costs and expensca which may in any way accn�c against said City
V z in con c a( the grandng of �his permi�
�'" APP UNDERSTANDS AND WILL COMPLY WI ALL NON-POIN7 Issued by: Date
SO R LATIONS.
'� Re-roofs
S' re �ant/Controctor Datc
HAZARDOUS MA'fERIALS DISCLOSURE Type of Rc�of
Will lhc applicant w futwc building accupant storc or handlc ha•rardous ma�crial
Jefined by �he Cupenino Municjpal Codc. CFiaptcr 9.12. snd �he Hcalth and Safcty
�� Scction 25532(a)? % All roofs shall be inspected prior to any roofing material being installed.
❑ Ycs Q No
�11 thc applicant or fuwre building occupant usc cyuipmcnt or Jcvices which If a roof is installed without first obtaining an inspection, I agree to remove
emit ha air conuminants u dcfincd by �he Bay Arca Air Quality Managcmcnt all new m� terials for inspecrion.
asU����
0 Ycs �J No
1 ha hvardnus mamrials requiremcnu undcrChap�cr6.95 of thc Califor-
nia Flcalth af Codc, Secuoat 25505, 25533 anJ Z5534. I wdcrsund thaz i( ihc building
dacs not urtc y ha a tenan4 Wa� it is my rcsponsibili�y w noufy the occupant af ihe
� n� x��o���u��orac�,;r�o � �� Signaturec�fApplicant Date
Owncr ut ` r a cnt D„� All roof coverings to be Class "B" or better