BLD-2020-0875BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 21853 WOODBURY DR Cupertino
APN: 326 45 046
PERMIT NO: BLD-2020-0875
CONTRACTOR:
SIMMITRI INC, P 0 BOX 1778 MORGAN HILL
CONTRACTOR PHONE:
4087793333
DATE ISSUED 6/25/2020 4:28:40 PM
ISSUED BY: JASMINE ARCHBOLD
VALUATION: $21000
JOB DESCRIPTION
KW)
(N) 21- PANEL ROOF MOUNTED PV SYSTEM - (6.7
LICENSED CONTRACTOR DECLARATION
AND
the
for
this
be deemed
ACOUSTICAL, C46 SOLAR
of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full
CONTRACTOR:
SIMMITRI
LICENSED
C39
LICENSED
765156
EXP
06/30/2021
I hereby
force
I hereby
INC
CLASS:
ROOFING, D24 METAL PRODUCTS, C-2 INSULATION
NO:
DATE:
affirm that I am licensed under the provisions
and effect.
affirm under penatly of perjury one of
I have and will maintain a certificate of consent
for which this permit is issued.
I have and will maintain Worker's Compensation
I certify that in the performance of the work
laws of California. If, after making
with such provisions or this permit shall
following three declarations:
to self -insure for Worker's
Insurance, as provided
which this permit is issued,
certificate of exemption,
revoked.
Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the
V
work
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
I shall not employ any person in any manner so as to become subject to the Worker's
I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith
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issued.
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Compensation
comply
HAZARDOUS MATERIALS DISCLOSURE
under Chapter 6.95
and the Health & Safety
as defined by
Code, Sections 25505,
of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance
I have read the hazardous materials requirements
the Cupertino Municipal Code, Chapter 9.12
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with
equipment
Municipal
Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use
the Bay Area Air Quality Management District I will maintain compliance with the Cupertino
25533, and 25534.
or devices which emit hazardous air contaminants
Code, Chapter 9.12 and the Health & Safety
EPA LEAD -SAFE DISCLOSURE
be responsible for this project.
Firm Certification No:
for this project.
An EPA Lead -Safe Certified Renovator will
Firm Name:
No EPA Lead -Safe Certified Firm is required
Certified
v
CONSTRUCTION LENDING AGENCY
is a construction lending agency for the performance of the work which this permit is issued (Section 3097, Civil Code).
Lender's Address:
I hereby
Yes
affirm
under penalty of perjury that there
No
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Lender's
Name:
APPLICATION CERTIFICATION
judgements,
all
that the above
of this city to
costs,
non -point source
information
enter upon
and expenses
regulations
is correct. I agree to comply with all city and county ordinances and state laws relating to building
the above mentioned property for inspection purposes. (We) agree to save indemnify and keep
which may accrue against said City in consequence of the granting of this permit. Additionally,
per the Cupertino Municipal Code, Section 9.18.
I certify that
construction,
harmless
the applicant
Signature:
I have read this application and state
and hereby authorize representatives
the City of Cupertino against liabilities,
understands and will comply with
days after its issuance, or if the work authorized on the site by such permit is suspended or abandoned for a period
of 365 days after the time the work is commenced.