B-2018-2165 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2018-2165
10830 ASHBOURNE CT CUPERTINO, CA 95014-6400 (375 22 089) FREE ENERGY
SYSTEMS INC
SAN FRANCISCO, CA
94104
OWNER'S NAME: DATE ISSUED: 12/20/2018
OWNER'S PHONE: PHONE NO: (800) 804-7958
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-46 Lic. #988918
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 X 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:
20-PANEL ROOF MOUNTED PV SYSTEM (6.6kW)
I hereby affirm under penalty of perjury one of the following two declarations:
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
permit is issued. Sq. Ft Floor Area: Valuation: $28050,00
APPLICANT CERTIFICATION
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 75 Number: Occupancy Type:
3
and state laws relating to building construction, and hereby authorize 375 22 089
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 y 'n consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally, the appl' nt derstand nd will comply with all non-point
source regulation Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature ate 12/20/2018 Issued by: Jasmine Archbold
.. Date: 12/20/2018
OWN - ILDER DECLARATION
I hffirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
folKow<ilnlgtwo 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 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)
2. I, as owner of the property, am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project (Sec.7044, Business & Professions Code), Date: 12/20/2018
I hereby affirm under penalty of perjury one of the following three declarations:
1. I have and will maintain a Certificate of Consent to self-insure for Worker's ALL ROOF COVERINGS TO BE CLASS "All
OR BETTER
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
2. 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, Sections 25505, 25533, and 25534. I will
permit is issued. maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
3. I certify that in the performance of the work for which this permit is issued I Health & Safety Code, Section 25532(a) should I st or handle hazardous
' material. Additionally, should I use equipments which emit hazardous
shall not employ any person in any manner so as to become subject to the air contaminants as defined by the Bay A Air uality Management Di 'ct I
Worker's Compensation laws of California. If, after making this certificate of will maintain compliance with the Cu tino unicipal Code, Ch r 9. and
exemption, I become subject to the Worker's Compensation provisions of the the Health & Safety Cod
correct. I agree to comply with all city and county ordinances and state laws I hereby affirm that ther a construction lending agency for the performance
relating to building construction, and hereby authorize representatives of this city of work's for which thpermit 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 ARC:H:I:TECT'S DECLARATION
Code, Section 9.18. I understand my plans shall be used as public records.
Signature Date 12/20/2018 Licensed
Professional