B-2018-0864 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0864
10221 STONY DALE DR CUPERTINO,CA 95014-1029(32637018) OWNERIBUILDER
10221 STONYDALE DR
CUPERTINO,CA
95014-1029
OWNER'SNAME:WEINBERG RICHARD AND TARA DATE ISSUED:07/10/2018
OWNER'S PHONE: PHONE No:None
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor OWNER/BUILDER Dale X BLDG X ELECT_PLUMB
I herebyaffirm drat I am licensed under the f Chapter 9 commenctn —MECH X RESIDENTIAL_COMMERCIAL
a provisions o p ( g
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in fall force and effect. JOB DESCRIPTION:
(N)5-MODULE ROOF MOUNTED PV SYSTEM-(2.5 KW);
I hereby affirm under penalty of perjury one of the following two declarations: UPGRADE ELECTRICAL PANEL(200 AMPS)
r. 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.
z. 1 have and will maintain Worker's Compensation Insurance,irs provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
Pei mit is issued. Sq.Ft Floor Area: Valuation:$6100.00
APPLICANT CERTIFICATION
I certify that 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 326 37 018
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 said City In consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 07-10-2018 Issued by:Kim Dunbar
Date:07/10/2018
OWNER-BUILDER DECLARATION
1 hereby 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. 1,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
�z.� ,as owner of the property,am exclusively contracting with licensed Signature of t
Applican
contractors to construct the project(See.7044,Business&Professions Cade). Date:07-10-2018
I hereby affirm under penalty of perjury one of the fallowing three declarations: ALLROOF COVERINGS TO BE CLASS"A"OR BETTER
r. I have and will maintain a Certificate of Cousent 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 1 have and will maintain Worker's Compensation Insurance,as provided for by l have read the Imzardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the perromon—of the work for which this Califon alit Health&Safety Cade,Sections 25505,25533,and 25534.I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
a. 1 certify that in the performance orthe work for which this permit is issued,I Health&Safety Code,Section 25532(x)should I stare or handle hazardous
shall not employ any person in any manner so as to become subject to the material.Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California.If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation previsions of the the Health&Safety Code,Sections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this pet hall shall
be deemed revoked. Owner or authorized agent:
APPLICANTCERTIFICATIONDate:07-10-2018
I certify that I have read this application and state that the above information is CONS'1'Rl1CfION LENDING AGENCI
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the perfo ance
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 ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
SignatureLicensed
Date 07-10-2018
Professional