12030093 I
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 23686 BLACK OAK WAY CONTRACTOR:SOLARCITY PERMIT NO: 12030093
OWNER'S NANIE: OPSASNICK EUGENE N AND STEPHANIE M 3055 CLEARVIEW WAY DATE ISSUED:03/192012
OWNER'S PHONE: 6509685109 SAN IIIATEO,CA 93402 PHONE NO:(6M)638-1028
LICENSED coNFRACrOR'S DECLARATION BUILDING PER INFO: BLDG r ELECT r� PLUMB r
Liccnse Class C— o Lic.M 2-60loV [ r ri
��/� MECH RESIDENTIAL COMMERCIAL
Contractors. lf4//—sL Date ;3:w—/'?—Ll
1 hereby a(7irnt tlnot I nm lieens I under the provisions of chapter 9 JOB DESCRIPTION: INSTALL ELECTRIC VEHICLE CHARGING STATION IN
(commencing with Section 7110 of Division 3 of the Business&Professions GARAGE
Code and that city license is in full force and effect.
1 hereby offiru under penalty of perjury one of the folloeing two declarations:
I have and will maintain a ceniticate 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 pennit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$1000
Section 3700 of the Labor Code,for die performance of die work for which this
permit is issued.
APN Number:34256013.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application laid state dial the above information is
correct.I agree to comply with all city and county ordinances and state Imus relating
to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon die above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless we City of Cupertino againslhabTties,judgments. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 D YS FROM ST CALLED INSPECTION.
granting of this permit. Add1h,,.1r11*1—
ally,the applicant understands and will comply
with all noo-poi I sou ce regions he Cupertino Municipal Code,Section //H, ,.�V ,) J
9.18. _ Issued by:`�/ y / / 9 / Date:
—�
SignatureDate / /7'y-
❑ O\VNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work.and lite stmcmre is not intended or offered for sale(Sec.7044, Signature of Applicant Date:
Business&Professions Code)
I,as owner of the pmpeny,am exclusively contacting with licensed contractors m
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
hereby affirm under penalty or.perjury one of the following three
declarations: HAZARDOUS MATERIALSDISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read lite hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code.Sections 25505,25533,and 25534. 1 will maintain
performance riffle work for which this pennit is issued. compliance with the Cupertino Phmicipal Code,Chapter 9.12 and the Health&
1 have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(x)should I store or handle Imzardous material.
Section 3700 of the Labor Code,for the performance of the work for Which this Additimudly,should 1 use equipment or devices which emit hazardous air
penin is issued. contaminants as defined by the Bay Area Air Quality Management District 1 will
maintain compliance with fullCupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of Onework for which this permit is issued,I shall Ilea(dn&Safety'Co .Secli is 25505,25533,and 25534.
not employ any person in any manner so as to become subject m the Worker's
CompcnsationpawsofCalipomia. If,after making this certificate of exemption,l *"ONSTRUCTION
gent:
become subject to the Workers Compensation provisions ,((lie Labor Code,I must -?'-If/7,
forthwith comply with such provisions or this permit shall be deemed revoked .
1-ENDING AGENCI'
APPLICANT CFRTI FICATION I hereby affirm dna there is a construction pending agency for the performance of work's
I certify that I have read this application and state that due above information is for which this permit is issued(Sec.3097,Civ C.)
eo tect.I agree to comply with of city and county ordinaees and state laws relating lender's Name
to building constriction,and hereby authorize representatives of this city aw cater
upon the above mentioned property for inspection purposes.(Ale)agree to save Lender's Address
indemnify and keep harmless the City id Cupertino against liabilities,judgniems,
costs,and expenses which may accrue against said Cily in consequence of the
granting of this pennit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: B1k: Lot:
APN . . . . . . . . : 34256013 . 00
DATE ISSUED. . . . . . . : 03/19/2012
RECEIPT #. . . . . . . . . : BS000016307
REFERENCE ID # . . . : 12030093
SITE ADDRESS . . . . . : 23686 BLACK OAK WAY
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : OPSASNICK EUGENE N AND STEPHAN
ADDRESS . . . . . . . . . . : 23686 BLACK OAK WAY
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : SOLARCITY CORPORATI
CONTRACTOR . . . . . . . : LYNDON RIVE LIC # 28844
COMPANY . . . . . . . . . . : SOLARCITY
ADDRESS . . . . . . . . . . : 3055 CLEARVIEW WAY
CITY/STATE/ZIP . . . : SAN MATEO, CA 94402
TELEPHONE . . . . . . . . : (650) 638-1028
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 1, 000 .00 1.00 0.00 1 .00 0 .00
1BSEISMICR VALUATION 1,000 .00 0.50 0.00 0 .50 0 .00
1CHRGSTA UNITS 1 .00 100.00 0. 00 100 .00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 101.50 0. 00 101 .50 0 .00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 101. 50 #12043
---------------
TOTAL RECEIPT 101 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
---- ------------------------ -------- ----------------------------
301 ROUGH PLUMBING 303 ROUGH MECHANICAL
304 ROUGH ELECTRICAL 313 ROOF NAIL
505 FINAL ELECTRICAL 5017 FINAL PLUMBING
508 FINAL MECHANICAL
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
7;
kAPN:
DRESS: 23686 black oak way DATE: 03/1912012 REVIE\VED BY:
)N: 1$1,000
*PERDtIT TYPE: Building Permit PLAN CHECK TYPE: Addition
PRIMARY SFD or Duplex PENTAMATION SOLAR-RES
USE: PERMIT TYPE:
WORK install electric vehicle charging Station in garage
SCOPE
Afeth.Play Check Plumb. Phut Cheek Elec,Plan Chcck
Mcz h. Peroth h'ee: Pl inh.Permit Fee: Fla•. Permit Fee:
Uthe+'Af&l hcsp. L1 I Other Plumb loop. Otho-Eler,. In Fp. El
if•,:h./nip. Foe. Plun+h..bup.Fee: Ftes./nip. Fee:
NOTE: This estinwte does not include fees due to other Departments(i.e. Planning,Public Works. Fire,Sanitan'Sewer District,School
District,e1c.). These fees are based on the trelininan in n enation available and are only an estinmte. Contact the Dept for addn7 info,
FEE ITEMS (FeeResolution'l1-053EA" 7/U/!1 FEE QTY/FEE I MISC ITEMS
Plan Check Fee: $0.00 F1 # Alternative Energy System
Suppl. PC Fee: Q Reg. O OTET 11 s $0.00 $100.00 ICHBGST4 EV Charging Station
PME Plan Check: $0.00
Permit Fee: $0.00
SuppI. Insp. Feel@ Reg. Q OT 0•0 1 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
C ans[rucliou Tax:
Adminislafive Fee: O
Work Without Permit? O Yes (j) No $0.00 1 G
Advanced Planning Fee: $0.00 Select a Non-Residential
Travel Documenlution Fens: Building or Structure �
Strong Motion Fee: IBSEISHICB $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $1.50 $100.001 TOTAL FEE: $101.50
Revised: 1/19/2012
RESIDENTIAL PROJECT COVER SHEET
Assessor's Parcel Number:
Name of owner. -P,kt—� (y
Project address. Z 36R6
Contact person. Phone. �—
•
Net square footage of lot.
Existing Proposed
Square footage: First floor:
Second floor:
Garage:
TOTAL: ;
Are there at least two 10 foot by 20 foot clear spaces inside the garage1) N
1s privacy protection planting required for the project? Y `
Build it Green Total Points
On what floor(s) is work being done? r
CCtM44U, `�Dom- 1OPMENT DEPARTME
Brief description of work. n$ �� eIc°(il l / V eVtflyLf�r(1Ui`jf/✓Z( TING 1 /�� vl Glgi✓zt-qe
APPRG`!E (�
This set of plans and specifications MUST be kept at the
Code editions: 2010 CBC (Y - N)2010 CFC L-s, r 20rIiOjGMIPucticgY jtN)untawful to make any
2010 CPC (Y- N)2010 NEC �"�F� anges or alterations on same,or to deviate
Califoraia Green Building Standazds�Cbde mwlthout approval from the Building Official.
The stamping of this plan and specifications SHALL NOT
be held to perr9ft or to be an apprqyai of the violation
Effective 1/01/11 of any provisl s,of eny kY nance or State Law.
BY
DATE
L -
' PERMIT NO.
�CEIVED � I • . - - .� .
MAR 19 2012 OFFICE COPY
' BY:
iw
Plan Review Process Work Book Page-8- Revised 12/21/10
f.
hrp# 0
by Coulomb Technologies
ChargePoint Networked Charging Stations
CT 1500 FAMILY
ChargePoint®Networked Charging Stations, by Coulomb Technologies, offer
municipalities, corporations,fleets,andutilities, high-reliability, plug-in electric vehicle
nRU
charging that drivers prefer.The easy-to-use stations provide multiple power options,
integrating aestheticsand ergonomics with sturdy construction—ideal for residential,
commercial and outdoor public applications.
The CT1500 family of charging stations provide 3.7kW (230V @ 16 A)charging and
are designed for public outdoor applications for the European marketplace. Charging
is delivered via a standard Continental (CEE7),UK (BS1363), or Australian (AS3112)
receptacle protected behind a locking door.
To enhance safety and eliminate energy theft,drivers access the outlet by unlocking the
L�tttntwww+++=�� door with a Charge Pass-card. The station's highly visible display guides drivers with
ION j instructive messages and can be used to display custom advertisement or greetings for
- T drivers.
.>' s Software Application Services
Set pricing and collect fees, provide 24/7 driver assistance,control access, display
advertisements, track usage, and diagnose the station remotely using the growing suite
of ChargePoint Network on-demand Software applications and a web browser.
,;:y_•. ;i Smart Card Reader
Provide optional driver billing and custom access control, preventing electricity theft
and enhancing safety,witti an integrated standards-based RFID reader that accepts
n Charge Pass cards, contactless credit cards, and Mifare-based transportation cards.
�r A
Intelligent Power Control
Ensure power is delivered only when a driver is authorized and the EV cord is property
x inserted.
Locking Door
_ a Protects power insertion point and retains the EV charging cord to prevent theft during
charging.
COMMUNITY DEVELOPMENT DEPARTMENT
Vacuum Florescent Display with Multiple Language Support BUILDING(DIVISION-CUPERTINO
Display instructive, advertisement, and greeting messages in many languages on thA ci. h ,.rrpcyttp IJ`display.
Integrated Fault Detection This set of plans and spa If cations:MUST be kept at the
• Ground Fault Detection: Integrated ground detection cucmt with auto ret[[yy ar� nvett notlh Ion,
p p lQr�C�1� 3ki�i^t`11iAtOa$'`s'Alr'fi�0 �t IF nfset',rT tom,er amr.
• Over-Current Detection: Disconnects ower to revert nui n c r I ' AT n.� D 3mte,of t0 deviate,noufication.
• Plug-Out Detection:Algorithm disengages power and notifies thPdrw�'r`wtfi;n a plug i�rem�s�ekl.
therefrom,without approval from the Building Official.
Over-the-Air Station Upgrade
e+o nIr ii+ inn�nrf cnnrinro in y o I I (�
Keep charging station current with future and evolving EV ch�eeing nerds bQ�ipgt�bir�station firmware�re�md[`ely ov'�r=thVal .
ba held to permit or to be anapproval of the violation
Utility Grade Energy Meter of any provisions of any City Ordinance or State Law.'
Provide accurate bi-directional energy measurement with integrated power metering circuitry.
BY
Remote Diagnostics and Control
Minimize the need for on-site maintenance with real-time reDATEma(arin nTUrIftoiiffg drTdY6nt ro1. Coulomb
PERMIT NO. .Ja95i.Technologies I
Network Interface
i
Wireless and cellular network interfaces allow seamless integration with the ChargePoint I ceolomu ucnnmogles,Inc.
Network and ChargePoint Network
Network a�prplication s�Ieei-vices. f 169]Dell Ave.
Smart Grid Coma I�IB��yV�+�' Gm It Irc CA 95007.6901 USA
US mil tree:mW)-3)o170)
"+t, rmw.cwlombtech.com
Enable Time-Of-Use(TOU)pricin and �j and response by integrating,wiih Advanced Metering w myth,epoinUnm
Infrastructures(AMIs). MAR l y Au I C �( ,
OFFICE (®PT CE KEUR e
I'M 71-MIM-01 Rev.2
chvarge 1# vnit'
by Coulomb Technologies
Specifications
CT1500 FAMILY
Electrical Input
Input Power 3.7 kW
• Input Voltage 230 VAC
Input Current 16A •,
Input Power Connections Line, Neutral, Earth
Required Service Panel Breaker 16 A breaker on dedicated circuit
Recommended Service Panel RCD 130 MA
Standby Power 5 W typical
Electrical Output
Output Charging Power 3.7 kW '
Output Voltage 230 VAC r
Output Current 16A
Output Charging Connector ; Continental (CEE7), UK(BS1363),or Australian (AS3112) '
Functional Interfaces
I Card Reader ISO 15693, 14443
Ground Fault Detection 20 mA CCID with auto retry(15 minute delay, 3 tries) i
Plug-Out Detection Programmable arm and trip current thresholds
' Power Measurement 2%@ 15 minute intervals;MID Class B capable(special order)
;.Local Area Network 2.4 GHz 802:15.4'dynamicrietwork w.
Wide Area Network I Commercial CPRS cellular data-network
Safety and Operational Ratings _ �p� ptyOPMENTDEPAIRTMENT
1 Safety Compliance 8 Certification.__-r IEC 61851.1, -21,-22; IEC 6095 ^1UNm� -fV'IPE1iTINO - — -_-- ---.-: -
Ot1 L22;�IECf605229=Tested an certified by DEKRA. Bears the CE mark and
j the KEMA-KEUR certificationmark. -�FPROVED. . _
Surge Protection 6 kV @ 3,000 A per IEC 1000-4-5. In geo raphlc areas subject tore supplemental
surge protection i ecomt4�rlded.ng g id specifications 1vIJa r
s( 11s Sm ,.N,L
i EMC Compliance EN55022 Class B: ilbb'the during Con tr icpf018 onts2fne Is a�to deviate
e.any - -
EMC Immunity I IEC1000-4-1. IEC 1000 4 2(11E D00's phot 5eP2p4roval from the Building Off dl8l-
ut
OperatingTemperature -30'C to�50'C (-22'Fto.122'f)'.
1 Operating Humidity_ I,95%nomcondensint�l3e stamping of this plan and speclflcetlons SHALL NOT
Enclosure IP44 be held to permit or to bean approval of the violation
Terminal Block Temperature Rating 1100•C (212' F) of any provlslons of any City Ordinanee�teor State-Law:
Maximum Charging Stations per 24. Each station mus� 1
be within 150 feet�litle.of sighMroP gawatS7�-- y station.
l 802.15.4 Radio Group 7�
Approximate Shipping Weights I Bollard (CT1561)25Rf(551bs i
I Pole Mount (CT 1502)FQfKg1'(Bd1lbs)
Wall Mount (CT1503) 15 kg(33 lbs)
oubmb ia1a'I r�'r..u�' �aTlpi'1fZ,.. _
CTerhrobgies,Inc,reserves Ne8_ re P dl ng Mspecllicntims at any time witlxxn notice,aM Is rot respa,sible la typographical agraphiol error W 1 maY appear in Un Eavea L
MAR 19 2012 "
BY: OWFICE COPTEMA
C I\EUR
• Sketch: = Top View
•ay
Mots 5
Sketch: = Side View
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION-CUPERTINO
APPHOVED
This set of plans and specifications MUST be kept at the
Construction Layout job site during construction. It Is unlawful to make any
changes or alterations on same,or to deviate
therefrom, without approval from the Building,Official.
Conduit (raceway) type to be installedtnob6 L- 61.rTplanandspecificationsSHALLNOT
Total feet of raceway needed: �S°IG to permit or to be an approval of the violation
U1 anv prowsions of any City Ordinance or State Law.
Pull points needed for job: 0n1e
BY
"Conduit run" -Job %: DATE
r
PERMIT NO.
Surface Mount: in0 % Raceway type: E541-K
Foundation Crawl Space Yk% Raceway type:
Attics Crrawl SDai r"t % Raceway type:
MAR 19 2012 4f UFRUE COr
Check all items required for this installation:
MC
P of
Required Materials items 1 PVC Rigid liquidtight flex armored
cable
conduit(10'section)
connector(indoor) 2
connector(outdoor) 0 i
coupling(indoor)
coupling(outdoor) /, I
Raceway straps 7-
LB
LB conduit body Ij
LL conduit body 11)
LR conduit body 1-9
Bushing-bonding D f
Bushing-plastic
Knock out seal(KO)
Locknut )
Locknut seal /
Junct box 4"x4"x2"
Junct box 6"x6"x4" 1
EVSE breaker type / I
other= e-1-0;E Al I LE l
other=
other= \
other=
Required wire type for wire
EVSE circuit length
wire 10AWG
wire 8 AWG
ROMEX 8-2 /
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION-CUPERTINO
panel(load center) breaker
additions p nel size panel type-' A PPROVED
/,- - type
main-panel / •• •--- -• ..........specifications MUST be kept at the
ruction. It is unlawful to make an
sub-panel �F���o��•s�.e ations on same,or to deviate y
breaker �- +h�res�,.., ,.�k�.:.,,.. pproval f-om the Building Official.
i no stamping of tnis plan and specifications SHALL NOT
Required wire type for be held to permit or to be an approval of the violation
panel(load center) wire length of any provisions of any City Ordinance or State Law.
addition BY
wirelOAWG DATE
wire
AWG
PERMIT NO.
wire 6 AWG
wire 4 AWG
wire 2 AWG
MAR 19 2012
131':-�� 5FFICE ®r
Coulomb (CTO EVSE Audit Report
Audit Performed By: Q " 1_Inkr ; Audit Date:
Customer Name: I2P 5V/LK
Property Location: play fA.(
Phone number: 115_0) 9C�8 -5/09
Installation type (circle one):
• Standard = surface mount EMT 565'
• Non-Standard = more than standard
<Standard> __ <Non-Standard>
:MMUNnY DEVELOPMENT DEPARTMENT
BUILDING DIVISION•CUPERTINO
General Scope of Work: APPROVED
u KAI Icy he ken'at the
I nls/a' e�•t,a, �-..:`.:__...
�IJI^l /PAI/FIL / S I h X 0 " !i rn" y r t /�I is /^I7i P`' .r make any
PL Pp G6 hanges or alterations on same,orzu.LuvIeie
hBreTrOm,WIl11UYl a11N...o, .. •. ..._ __., _n'sClal.
/,TC c;-60 I,J,LLS /��!
Plr n s rnar nr Nn ,, ,..•,'. ..,.-NOT
''V��/ [ �D1,��/� Zo�Vne vlolatlon
/J0 q0,4 -•, nr ,4slr • 4111 ,Ev -.ate Law.
m A. _
• PFRMIT NO
��+ CFb�T1R`lrll
MAR 19 2012
Property Information
Requested parking location for EV: S 1p'q� .
Requested EVSE installation location: . rE 2zio X- SL,,) 6,AXA(* W' L
Home Square Footage: ,
Year built: ZOO 1
t� Electrical - MAIN Service Panel Information
1. Electrical service utility: P Ca L E-:7-
2.
2. Service entrance: Overhead Undergound
3. Main service panel rating:
4. Service panel brand: /r--ln I S
5. Service panel model: I LO
6. EVSE circuit to be built from main panel location? Yes_No_
7. Distance from main panel to EVSE: —,r
8. EVSE circuit to be built from sub-panel? Yes—No
9. Sub-panel rating:_ Al
10. Sub-panel brand:
11. Sub-panel model:
12. Distance from sub-panel to EVSE: A 71,1A
13. Panel mount type: flush mount- surface-mount-'
14. Breaker type we will be installing:?- ;Po`E Llo{-7 / //
Electrical Notes:
SNrrT Dot,)IQ Ptd i�L b DR•r1,L �/rte r !-10L-6
�PAQoUG.N U 0o1-1 �A��yuLAUNI Y DFGEp� E�N'��AEFA�9T�
nc5 nar 1 s/ i tl �,C FJSi yiJit�P.( .., fP�o�rin + I le�ALLl
r Itvvw
('t 114,t-
J I III/"'Ju, u, UIQI IJ uuu Dv,. nuyv�l�m/rv��w�..: o[�ncN• e. fla
4 f f L.13 t LI,� Ir,t //J ul)lTrnnv^ 'n / 1L(//.tJ, I 7T 6 3 any
r_
In)}?LC S f� 17r�1 Pf60's orClt
tneretrom,wanout Approval l:onl ule ouuunly�uwr
The stamping of this plan and specifications SHA OT
i anv nrnvlslonc of anv Citv Ordinance or State Law.
DATE
Additional Notes PERMrrNO.
1. Is the property a good candidate for solar? es No
Customer name EU ='N S
�,iCFit l ,� „
MAR 19 2012 2 E
Ply
BY:._ �—
Electrical Appliances - LOg DLT �QU 12D
List all major electrical appliances and fixed appliance pumps & motors.
Major Qty Make/ Model KVA Rating: (Typical /Actual)
Appliances
Range Oven
Microwave Oven
Cook Top
Cook Top Hood
Plate Warmer
Toaster/Griddle
Disposal
Trash Compactor
Dishwasher
Refrigerator
Freezer
Clothes Washer
Clothes Dryer
Steam Room
Sauna Heater
Pool Pumps
A/C Unit 1
A/C Unit 2
A/C Unit 3 oT�eoNT
Tread mil l Coty oMUNITY D DMSION"CUPERTINO
Wine cooler D ROVED
Landscape lights a,erifications MUST be kept at he
Whirlpool spa
�nh site di ring construction. It is uQrawrto deviate ^ ry
Other char,leslor annio: offici d.
Orrrn o,, ,,,, .._
�nnroval from the Building
ther
Other Tnestat �V :"
sed soeciflcations SHALL t IOT
tie in
hai + oermft or to be an approval of me 2
titt 1_e W.
Other of any p ovislons of any t;Ity V'U.'.. --
Other _
' DATE
�v s PERMIT NO.
MAR 19 toll
1,C�-3 0 9
ALTERNATIVE ENERGY PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 AE
CUPERTINO (408)777-3228• FAX(408)777-3333• buildina(akupertino.org
PROJECT ADDRC9S APN 0
OWNERNAMii 1 f PUONr ry r-]IAu.J/
S'I'FEET ADDR� S V CITY,s,)Y1Y b—
CONTAM NAL\IE ,I PI[ONE: (, IiMAIL
W
S'rRE17ADDRISS CIIY,SrATI:, ZIP FAX
I
❑OWNER ❑ OWNIm-BURDER ❑ OWNPRAGENICONI'RACIOR 11CONrRAMORAGFsF1 ❑ ARCHUECT ❑ENGINEER ❑ DEVELOPER ❑TIINANT
CON-TRAM OR NAME V .ICENSIi NL'2f( A�Sf O LICC9SETYPE RU
COMPANY NAME E.`AII.j� (�� ( FAA �'��\--• —119A
SI'RHET ADI) SS Crr '1v,' PHONE
Y Q
ARCHITECT ENGINEER NA\IE SHNUMBER BUS.LIC a
COMPANY NAAIIi Ii-MAI, FAX
SNRCFCFADDRISS CITY,SIAI'P ZIP PHONE
USE OF )<1 FD or Duplex ❑ Multi-Family PROJEM IN WILDLAND PROJECr IN
$'rRtJMURI:: ❑ Commercial URBAN IN'IERFACEARRA Yes ❑ No FLOOD ZONE ❑ Yes ❑ NO
❑SOLAR PANELS I IILECTRIC VEHICLE CHARGING SI AT1ON ❑ SOIARWATERIIEATING ❑ 0111ER:
FOR S'DIAR PASELf: NUMBER OF PANEI-SIUNITS: AILOWATTS(COMMERCIAL ONLY): TOTAL V l'I N:
U7J.
DESCRIPTION OF WORK
ev
RECEIVED
By my signature Mlow,I cenify m each of the follow' g: I am he properly owner or authorized agent to act on the pmpeny ov/\ner's behalf. 1 have read this
application and the infomwtion I hav•pro fled is co :m. I ha.•read the Desenpption of Work and verily i1 is accurate. I agree b comply with all applicable local
ordinances and>mtc lows rcluting m wl i g conswc on. 1 m horizc rtpasnl Gtives or Cupertino V)enter the above-identified pro{xny li)r inspection purposes.
Signature of ApplicanllAgeneCVIDalc: J M/�
SL i I PPLBAtEN'T 1 INFORMATION REQUIRED OFFICE USEONI.1.
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PI'App_201 Ldoc revised 03/16/11