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12070253 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22036 ACACIA WAY CONI'RACfOR:HORIZON ENERGY PERNII 'NO: 12070253 SYSTEMS OWNER'S NAM Ii: 1'01305320612 DATE ISSUED:07/312012 OWNFR'S PHONE: LOS GATOS,CA 95032 PI IONF,NO:(408)97M I I ❑ LICENSED CONI'RACI'O�/R'S DECLARATION .1011 DESCRIPTION: RF,SIDENI7AL❑ COMMERCIALE] License Class Lic.d �.G ?.��/ INSTALL IJ ROOF MOUNTED SOLAR PANELS 3 K.W Cherchs r e�� i 7�i-l2 I hereby a firm that I am license un er Ibe prvwi+ion+nf Chapter 9 (commencing with Section 7000)of Division 3 of the Businea+& Professions Code and that my license is in full force and effect. 1 hereby affirm under penalty of perjury one of the fallnming(eso declarations: 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. Sq.Ft Floor Area: I Valuation:$23400 1 have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the perfor n mcc of the work for which this ANN Number:32602075.00 Occupancy Type: permit is issued. A I'I'IJC,\\1'CIiK'I'I FIC.V1'10\ I certify that I have read this application and stale that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinmmccs and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYO- costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicmu understands and will comply Issued by': Date: / with all non-point source regulaf ns per the Cupertino Municipal Code,Section 9.18. 7-31 Ili RE ROOFS: Signature installed without first obtaining an inspection,I agree to remove all new materials for inspection. ❑ O\\'NEIi-I3I11LUF,K DISCI,.A R.VI'ION Signature of Applicant. Dam: hereby affirm That 1:hat exempt from the Contractor's License I,aw formic of the following Iwo reasons: AI,1.ROOF CO\'4;KINGS'f0 DF,CLASS"A"vR Rh;'1-fh;R 1,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not intended or oflered for sale(Sce.7044, Business&Prolcssions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to IIA'ZARDOIIS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Prolessions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the California Ileallh&Safety Code.Sections 25505,25533,and 25534. 1 will 1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cuperlino Municipal Code,Chaplet-9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous I have and will maintain a Certificate of Consent to self insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air conlaminam s as defined by the Bay Area Air Quality Management District 1 performance of the work for which this permit is issued. will maintain compliance with the Cuperlino Dlunieipal Code.Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code, I certify that in the performance of the Work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificatc of exemption,I CONSTRUCTION LENDINC AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply With such provisions or this permit shall be deenled revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANTCERTI FICATION Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinmhces and slate laws relating to building construction,and hereby authorize 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, ARCII I'I'I?CI"S DECLARATION costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and Will comply with all non-paint source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION ADDRESS: 22036 ACACIA WAY I DATE: 07/31/2012 REVIEWED BY: SYLVIA \I APN: I BP#: 'VALUATION: 1$23,401 1 *PERMIT TYPE: Building Permit I PLAN CHECK TYPE: Alteration / Repair PRIMARY PENTAMATION USE: SFD or Duplex I I PERMIT TYPE: SOLAR-RE WORK INSTALL 14 ROOF MOUNTED SOLAR PANELS 3 K.W SCOPE ,tech. Plan Check I I Plumb. Plan Checlr I I Elec.Plan Check "ech.Permit Fee: I Plumb. Permit Fee: I Elec.Permit Gee: Odicr dlech.Insp. Other Plumb Insp, u Other Elec.Imp. ,ble.ch.la%P. Fee: Plumb. bryt.Fee: Flee.Insp.Fee: NOTE: This estimate sloes not include jeev clue to other Departments(i.e. Planning, Public Works, Fire,Sanitan•Sewer District,Schaal District. etc.). These fees are based nn the prelinrinan•information available and are only an eviitnate. Contact tire Dept for addn7 info. FEE ITEMS (Fee Resolution 11-0531-17' 711111) FEE QTl'/FEE I MISC ITEMS Plan Check Fee: $0.00 0 # Alternative Energy System Suppl. PC Fee: Q Reg. 0 OT 10.0 I hrs $0.00 $219.001 1P/1OT011RES Photovoltaic System r PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee.,0 Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME" Permit Fee: $0.00 Construction Tax: n Administrative Fee: O Work Without Permit? 0 Yes Q No $0.00 I I G Advanced Plannine Fee: $0.00 Select a Non-Residential E) Travel Documentation Fees: Building or Structure 0 i Strone Motion Fee: 1BSE/SMICR $2.34 Select an Administrative Item BIda Stds Commission Fee: 1BCBSC $1.00 I SUBTOTALS: $3.34 $219.001 TOTAL FEE: I $222.34 Revised: 07/01/2012 HORIZON ENERGY SYSTEMS Date: July 30, 2012 Electrical Calulations and Product Culsheets Q For I'V (Solar Electric)System ?Ij. �.sp Its G D Customer: Stephen Chan Address: 22036 Acacia Way Cupertino,C CUppRTINO I I ES Joh#: 1457 Building Department �T JUL 31 2012 Horizon Energy Systems, Inc. REVIEWED FOR CODE COMPLIANCE Eric Stevens,Technical Director eric @horizonenergysystems.biz. Reviewed By: www.CoSolarNow.com 408-978-0111 BUILUUVU�,••—. . n F� 11"TM' O O , Ut 11 ` M- Appp,OVED ENT Comm BBB°, P v N O O This b site during cn struction. It,,Unla job to make any ^deviate changes or alterations onrsamhe Building ng Official. , therefrom,witiVO'BO\'32W12 - LOS C �7-OS - CA 95032 - (408) 978-0111 - (FAX) 440-518 1'v 11217 t',IL''oCO',IjI2A!TORE1326 CONTRACTORS LICE, 83 The stamping permit'or 1. "ova ut ..�. •. 1 be held to permit or to be ity Ordinance or state law. of any pro, ns of any BY 7 01 / -2 DATE �7Od�-�, PERMIT N0. //N^`\\ 1 MON110N���CF l��94""' 'e sa, KP IIOOal1.�icl�A�$Y'+l0 PV`���Elegy Q�armO�O' A01 GMn0.aap° WM CuG°PNro.CP MFSt`SQMCe Pa ��PAN Inverter Output Circuits(AC) Branch 1 Branch 2 Inverter Ratings #of Inverters: e 6 Inverter Model: M210 Conductor Size: #12 AWG 912AWG Utility Service Max.Conlinous AC Output': 0.88A Conductor Type: THWN-2 THWN-2 Max.OC Voltage Input: 62 V Wire Ampacily': 13.92 A 13.92 A Nominal AC Voltage Output: 240 V Circuit Isc': 8.8 A 6.6 A Conduit Specs: Conduit Size/Type: 12"/EMT #of Conductors: 4 #6 AC GEC M Bare CU AC GEC':#8 AWG Stranded 8 Inverter Branch Circuit Main OCPD 6 Inverter Branch Circuit t J-Box I l' Combined Output Circuit(AC) Conductor Size: #12 AWG Conductor Type: THWN-2 Wire Ampacity: 24.6 A Solar Combiner(AC) Circuit Isc: 15.4 A Service Panel Rating Conduit Specs Bus Amp Rating: 200 A Conduit Size/Type 12"/EMT Service Voltage: 240 V Bus Amp Rating: 60 A #of Conductors 3 Main OCPD Rating: 200 A Feeder OCPD Rating: 20 A Total System OCPD Rating:-20 A System OCPD Rating: 15115 A AC GEC:#8 AWG Stranded HORIZON ENERGY SYSTEMS ' Box 320612 Los Gatos, GA (408)978-0111 Notes: PV (Solar Electric) Grid-tie System 1.See Calcs page for Voc, Isc,and Ampacity calculations 2.AC GEC sized per NEC 250.66 Drawing No. 1 Module Rating at STC Temperature Coefficents Roof Loading Module: SunPower SPR-245NE-WHT-D Roof High Temp: 0.58 Imp: 6.05 Amps Ambient High Temp: 0.82 SunPower SPR-225E Weight Vmp: 40.5 Volts Cold Temp: 1.17 14 Modules @ 33#per module 462 lbs. Isc: 6.43 Amps Voc: 48.8 Volts Branch Conduit Specs 0 UniRac SolarMount 0 Wire Size/Type: 1#12 THWN-21 1 UniRac SunFrame 70 lbs. Inverter Rating Number of Conductors: 4 Model: Enphase M210 Adjustment Factor: 0.8 Total: 532 lbs. MAX AC Ouput Current: I 0.88 Amps I Output Rated Continous: 1.1 Amps I Conduit Specs Total attachment points: 18 Wire Size/Type: 1#12 THWN-2 Number of Conductors: 3 Weight per attachment point: 29.6 lbs. Adjustment Factor: 1 Area per module: 13.4 sf Total: 187.6 sf Roof Top Inverter Branch Output Characteristics Roof load: Per Square foot: 2.8 lbs. Branch Ampacity Calculations (2 branches of this size) Pnverter Out p u?of Inverters Continous) Derated Derated Conduit Fill Temp Wire I All penetrations sealed in a workmanlike manner. COurBrant I inbranch D.25e I Outpu6t6l ` I Amp,31921 0.8 I Oe58e I Ampacity I1I Roof Framing 2x824"OC Comp Branch Ampacity Calculations Inverter Out p up of Inverters Continous Derated Derated Conduit Fill Temp Wire I Current I in branch De25e I Outpuut8l ` I Ampacity 0.8 I oera8 a Am3p0acity Common Neutral Sized at#12 Each branch circuit interconnected with a 15 Amp breaker Total System Output Characteristics System Ampacity Calculations Inverter Out p I u9#of InverterslContinous Derated Derated Conduit Fill Temp Wire Current in branch I De25te Outpst4l < I Ampa24 6 1 DOe82 a I A 30acity System interconnected with:) 20A Breaker 'All work to conform to 2010 CEC ' 5 Y it Y"^�f' •�' t '���G,�" -a �t`r,f}1�*+� .yW��r�r r.� Y L�r�� w�"xl"�i -.!,. • �'�u '�t���4ry.� r 'IC�� !�F` �e r �,"r NWE yt,S.3�-�'iy •i' 'f,9 r i 3 � t .� 5� �.}., i {'Y. p4•e t g y t i ' r .!� t" � � 1 t r Tyi .�lt:.11 7s i_ux74`-L� �yb(•4-+. J�b"N*J•n�'itsfA�i •�l�j�bP`Lti . }1r-a�..�'f1e�.� !. I .��'R�VS���R�t _I" `3 � y tiL � '�y?y 2�• o% A,#�P!!'i NN�ll�+1) S' . C '� �-: ,�f`a• * '���� s4 �',Y• 4+6+. ���4. 732.R 5�`, � �•y.��•})�r�'� �i 0�/O � '�' `-' •y a. M !llry'1�� 4iN� iq t 4 Jill Nl MODEL: SPR-245NE-WHT-D ELECTRICAL DATAr r . V rLV;CORVE, AM,-1m SamMnd L,r Gn4Hm,ISiCI:indlmne J IOOOW%m•,,aq•15;nM".41p-.1;23'C Peak Power(+5/.3%) Pm ox 245 w I 7 I I 1 1000 WA. ]mI 56c t Cell Efficiency 22.9% 6 1000, I I Panel Efficiency It 19.7% 4 Rated Voltage VmPIP 40.5 V I e• _ \� 3 Rated Current Imi 6.05 A I V 2 I sae W/aP I �) Opeo-Circuit Voltage Va 48.8 V Short{ircuil Current Iu 6.43 A I W/'"' I I Al 0 Maximum System Voltage JUL 600 V I 0 10 20 30 40 50 Temperature Coefficients Power IP) -0.38%/K I Voltage M Voltage Noc) -132.5 mV/K I Cumem/voltage characledmu vdth dependence on irradlanu and module n mperature. Current 11.) 3.5 mA/K Noa 45°c./-2°c I I "_.'TESTED``OP,ERATINGICONDI,ITfONS Series Fuse Rating 20A I I Temperature -40•F to+1 BY F(-40•C to+850 C) Grounding Positive grounding not required I Max load 113 psf 550 kg/m]15400 Pal,front(e.g.snow) w/specified mounting configurations MECHANICAC`DATA•.__ I 50 psf 245 kg/m'12400 J front and back Solar Cells 72 SunPower Moxeon"'cells I (e.g.wind) Front Glass Higlftransmission tempered glass I I Impact Resistance Hail: (25 mm),at 51 mph(23 m/s) with anti-reflective(AR)coating 11 Junction Box IP-65 rated with 3 bypass diodes Dimensions:32x155x 128 mm I - /ARRP;N_T_IES`,,`AND_,,Cl F ICATI- NS Output Cables 1000 mm cables/Multi-Contact IMC4)connectors I I Warranties 25-year limited power warranty Frame Anodized aluminum alloy type 6063 (black) I I 10-year limited product warrant Weight 33.1 lbs. (15.0 kg) I I Certifications Tested to UL 1703.Class C Fire Rating DIMENSIONS MM (A)-MOUMING HOLES IS)-GROUNDING HOLES _.IIDI.+s1 W 1210&61.261 10x04.26171 $,][?z]ol JI I9017077 ._,2 ; TT_ TTTITTTTr ebfH �R % I ` P- ENDS) �) I -- I ri a rrTTT I&w Iel.Oel I aaflbl) - -- IA 9aw[nz+ll � --I rz( 171 , iseslsa4sl Please read safety and installation instructions before using this product, visit sunpowercorp.com for more details. e,oils.re..cue,.suNrow¢.n.sew.,..laa,.em,HEwoaLOssrnrmxoroesolAC,e,�eM.,eoN,,..,a.,,ms,>,egi,,.a„m.,wLr sunpowercorp.com r15Wbw Capamon H Au U6 od dhe oaww,v,ad N LgM Pwn.d `-rK4mo•r mrLdd n the dmd1,..m„6i.n bdwg.Witlwu mike Dmmwq repld544a Arv•8/I14-aJ 611 41 IJ ENPHASE MICROINVERTER M210 o iL - Gt I• ,ems : The Enphase Energy Microinverter System improves energy harvest, increases reliability, and dramatically simplifies design, installation and management of solar power systems. The Enphase System includes the microinverter, the Envoy Communications Gateway, and the web-based Enlighten monitoring and analysis website. Maximum energy production PRO()ucTivE Resilient to dust, debris and shading - Performance monitoring per module - System availability greater than 99.8% RELIABLE [ _ No single point of system failure SMART Quick & simple design, installation and management 24/7 monitoring and analysis SAFE Low voltage DC Reduced fire risk ®® c us MICROINVERTER TECHNICAL DATA k ..Input,Data,(DQ z. .. ; M210o8a-. 8- 12, MZio-'sn-z9as z:: ' Recommended input power(STC) 240W 240W Maximum input DC voltage 62V 62V Peak power tracking voltage 31V— 50V 31V—50V Min./Max. start voltage 38V/62V 38V162V Max. DC short circuit current 12A 1 12A Max. input current 10A 10A ` Outptat'Data;(AC):.;. - : • Maximum output power 210W 21OW Nominal output current 1.00 A .88 A Nominal voltage/range 208V/183V-229V 240W21 1 V-264V Extended voltage/range 208V/179V-232V 240W206V-269V Nominal frequency/range 60.0/59.3-60.5 60.0/59.3-60.5 Extended frequency/range 60.0/59.2-60.6 60.0/59.2-60.6 Power factor >0.95 >0.95 Maximum units per branch 18 13 Efficiency' Peak inverter efficiency 96.0% 96.0% CEC weighted efficiency 95.5% 95.5% Nominal MPP tracking 99.6% 99.6% Mechanical•Data.. , ., .. .. v.. ... ,.. - . ..�,�... .... . ..:. .s 4,,. Operating temperature range -40°C to +65°C -40°C to +65eC Night time power consumption 30mW 30mW Dimensions(WxHxD) 8" x 5.25" x 1.25" Weight 4.4 Ibs Cooling Natural Convection—No Fans Enclosure environmental rating Outdoor— NEMA 6 rFeatures _.:. Communication Powerline Warranty 15 Years Compliance UL1741/IEEE1547 FCC Part 15 Class B Enphase Energy, Inc. 142-00006 REV 04 201 1st Street, Suite 300, Petaluma, CA 94952 877 797 4743 enphaseenergy.com 0 Printed on 100 percent regded paper. Y ENE PV MODULE FRAMING AND MOUNTING SYSTEM FOR PITCHED ROOFS RGY�SYSTEh1S4-''+ I YY l lj '4i b r h I i I 116 Components I. Inter-module rails provide support shelves for the modules. They rest as little as 2.125 inches above theiroof. 2. Full-length cap strips 'secure modules and finish the array topside, forming a gap- free frame. Self-drilling screws provide holding power. 3. End caps finish rail ends to complete the frame. 4. L-feet attach directly through asphalt shingle roofs and support the rails 0.75 or 1.75 inches above the roof surface to provide convective airflow for ventilation. 5. Splice bars safely extend rails. 6. Standoffs (optional), designed for standard flashing, support L-feet above tile or shake roofs. A range ofiheights ensures a low profile. I I With your array in full view, the sunshine rule applies - It has to look good. Properly installed, SunFrame"I complies with the Uniform and California Building Codes. The mounting system provides the necessary structural integrity for your array. It also meets UniRac's own high standard of installation friendliness, both initially and whenever modules need repair or replacement - or the roof needs replacement. But it is aesthetics that truly sets SunFrame apart. It's the only PV module mounting system designed from the outset to enhance the appearance of the home. A completed installation blends handsomely into the roof, becoming a part of the house like a skylight. I I I Flat Jack(D composition shingle roof mounts provide a low-profile, roof integrated look for solar panels and other devices. This mounting system provides positive water proofing, eliminating the need for sealants. "We pride ourselves on quality, aesthetics and 1 performance. Using TTI Flat Jack and Flush • Designed specfically for Mount products gives us that edge. The biggest pitched composite shingle advantage is peace of mind from roof leaks with roofs ! the TTI Flat Jack flashing System." • Minimal or no shingle cutting required I Roy Phillips • Installation is 25% faster than standard mounts resulting in lower installation costs i • Low-profile design enhances aesthetics while allowing ventilation and drainage I I • Extremely durable and corrosion-resistant I p i • Provides positive waterproofing • Wind resistant to 130 MPH 'at IBC Exposure D • Can also be used to mount! antennas, solar thermal, flagpoles, air conditioners, etc. s www.thompsontec.coni Tel: 415.446.0103 Thompson Technology Industries, Inc. Fax: 415.883.7915 16 Digital Drive, Novato, CA 94949 i Email: info @thompsontec.com 11:151 1 11 IMIN 1111!111 1- J r, Z CAUTION : SOLAR CIRCUIT ; I Th-is Electrical Service is Also Served by a . Photovoltaic System ♦ Solar System 1 AC Disconnect ) AC Disconnect Solar Photovoltaic System Operating Voltage 240V un�Rsc e Sv�F�atr+ seta* Me lute Rpet'm9 . mate`vat �o s„eatt+ta9 mate`%at 16 Lag °\enetat�,e ant° ikaF\ex 1 p sti 5I 117' R`in-P d With S M9 2 sea outs Fiat)ack F�a etratiO�s n ar°h°r P p\�Per betv+ee imam c31i spa x t less) engi�eetir9 4 m % bo\t eve�Y V iliac li e,ia9 to cool v to aMee6r SIt 9�tt1 instaiiatiOerts oN cn NOg\Z s G*tobr m $ca\e eQo. m 92 '12 UO Gc,d tte SYste t QV lgo\ac gee°«icl pcaW�a9 N0' Module Pnaehmer owit, re SYs�e^' 3 unF�ar"e m V M°av`e P�acht�`ent Uci,Ra6s P ALTERNATIVE ENERGY PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 AE CUPERTINO (408)777-3228 • FAX'(4/08)777-3333•buildin0(a)cuoertino.orG PROJECT ADDRESS LAC/0. (/✓[Ly I APN a 6 n ' ^ (A ij O—1 `� OWNERNAME FYA2-Z036 p e�� / I PHONE 62 —7 IIJE-GNAIL I J STREET ADDRESS CITY, STATE.ZIP FAX 22036 �(6tcla l/�aY e o 9Soll CONTACT NAME . K/C S)�C✓fA/S / PHONE'/^-? E-MAIL STREET ADDRESS Bi/y /J�J�ry,PA ��a/L�F CI IV.STA IS.(zi P. / FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME (` LICENSE.NUMBER LIC.EENSI Y 4 I BUS.LIC 0 ,(r10A) �iyC.Cg J 1�as 8298.E OO t�''�1 COMPANY NAME ���� / E NAIL 1 / _ FAX H16kJWAJ ✓ r-449V S/C/NS C2 i[�(roru I_G-+ NC1.9 rka,s/�zZ J STREET ADDRESS q, CITY,STAyE.ZIP / L PHONE/J �Q .7 G+ Lps• (74 H 9So3� ll�i ARCHITECT7ENGINEER NAME LICENSE NUMBER BUS,LIC B COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE.ZIP PHONE USE OF �<SFD or Duplex ❑ Multi-Family PROTECT IN WILDLAND PROJECT IN STRUCTURE El Commercial URBANINTERFACE AREA Cl Yes C1 140 FLOOD ZONE (j Yes C1 No )(SOLAR PANELS I ❑ ELECTRIC VEHICLE CHARGING STATION ❑ SOLAR WATER HEATING ❑ OTHER: rFONS01ARPANELT, N'OMBEROFPANELS/UNITS /LI uKILOWATTS: J'J TOTAL VALUATIO/2,/��% DESCRIPTIONOFWORK l RECEIVE Y' By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on ire Q556cny owner's behalf. 1 have read this application and the information I have provided is COUCCL I have read the Description of Work and verify it is'accumte. I agree to comply with all applicable local ordinances and state laws relaat' ,to building construction I\eN�p'nz representatives of Cupenino to enter the above-identified property for inspection purposes. Signature of ApplicanUAgr,At — �... Nti \ _ D);p, / -J1- 12 (( SUPPLEINIENTAI,INFORMATION REQUIRED OFFICE USE ONLY _ -THE.-COUNTER —((( ❑ EXPRESS U U 4 ❑ STANDARD L i 2 O URGE ELMAJOW PVApp_2012.doc revised 06/20/12