B-2019-1213 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2019-1213
21600 RAINBOW DR CUPERTINO,CA 95014-4815(366 38 030) N R G CLEAN POWER
INC
CANOGA PARK,CA
91303
OWNER'S NAME: DATE ISSUED:07/16/2019
OWNER'S PHONE:909-488-9726 PHONE NO:(800)698-6627
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class b Lic.#1026168
Contractor N R G CLEAN POWER INC Date 04/30/2021 X BLDG X ELECT —PLUMB
MECH X RESIDENTIAL_COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
(N)25-PANEL ROOF MOUNTED PV SYSTEM(8.25 kW); (N)OUTLET
hereby affirm under penalty of perjury one of the following two declarations: FOR FUTURE EV CHARGER.
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.
2. 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:$25000.00
APPLICANT CERTIFICATION
certifytha ave read this application and state that the above
informatio
Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature < Date 7/16/19 Issued by:Haley McKee
'11\/ Date:07/16/2019
OWNER-BUILDER DECLARATION
I 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. 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:7/16/19
I hereby affirm under penalty of perjury one of the following three declarations: 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. HAZARD OU
and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:7/16/19
I certify that I have read this application and state that the above information is CONSTR N LENDING AGENCY
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 performance
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. I understand my plans shall be used as public records.
Licensed
Signature Date 7/16/19
Professional