B-2018-0703 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0703
22361 SANTA PAULAAVE CUPERTINO,CA 95014-2715(357 04 058) FREE ENERGY
SYSTEMS INC
SAN FRANCISCO,CA
94104
OWNER'S NAME: DATE ISSUED:0427/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-46 Lic.#28f91.8
Contractor FREE ENERGY SYSTEMS INC Date 12/31/2019 x BLDG ELECT—PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing —MECH$RESIDENTIAL—COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license Is In full force and effect. JOB DESCRIPTION:
(N)16-PANEL ROOF MOUNTED PV SYSTEM(5.28 ICV)
I hereby affirm under penalty of perjury one of the following two declarations: REV 91-CHANGE ROOF LAYOUT-ISSUED 5/9/2018
1. I have and will maintain a certificate of consent to self-insure for Worker's
mpensation,as provided for by Section 3700 of the Labor Code,for the
efformance of the work for which this permit is issued.
it is issued. Sq.Ft Floor Area: Valued—$22440.00
APPLICANT CERTIFICATION
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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 357 04 058
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,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against Id ity In consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the tic t understands and will comply with all non-point
Source regular
ereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed,If a roof is
1. I,as owner of the property,or my employees with wages as their sole installed without fust obtaining an inspection,I agree to remove all new materials far
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(See.7044,Business&Professions Code)
z. I,as owner of the properly,am exclusively contracting with licensed Signature of Applicant
contractors to construct the project(Sec,7044,.Business&Professions Code), Data 5�/018
I hereby affirm under penalty of perjury one of the following three doelm ationso ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. 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
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sultans 25505,25533,and 25534.1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
s. I certify that in the performance of the work for which this permit is issued,I health&Safety Code,Section 25532(a)should I store or handle hazardous
shall not employ any person in any manner so as to became subject to the material.Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area it Quality Management District I
Worker's Compensation laws of California.If,after making this certificate of will maintain compliance with the Cupe unlet ode,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save Indemnify and keep harmless the City of Cupertino against liabilities,
Judgments,costs,and expenses which may accrue against said City In Lender's Address
consequence of the granting of this permit.Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCITECT'S DEC
LARATION
Section 9.18. 1 understand my plans shall be used aLARATIONs public records.
Signature Dates 018 Licensed
Professional