12100212 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21431 VAI AVE CONTRACTOR:SOLARCITY PERMIT NO: 12100212
OWNER'S NAME:
SAN M1A'I'EO,CA 94402 I'IIONE NO:(650)638-1028
LICENSED CON-TRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT IJ PLUMB r
r
License Class . Li,k i c r - NIECIIr RESIDENTIAL r' COMMERCIAL
Contractor J0 — CL—
I hereby affir m that I anrcensed under the provisions of Chapter 9 JOB DESCRIPTION: INSTALLATION OF ROOF MOUNTED SOLAR SYSTEM
(commencing with Section 7000)0f Division 3 of the Business& Professions WIT!!
Code and that my license is in full force and effect. (19)MODULES(4,561(W)
I hereby affirm under penalty of perjury one of the following two 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.
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance oldie work for which this Sq.Ft Floor Area: Valuation:$26000
permit is issued.
AIT LICANI'CER'T'IFICATION AI'N Number:36205018.00 Occupancy Type:
I certify that I have read this application and state that the above information is
correct.I aeree to comply with all city and county ordinances and state 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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the a plicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regul.4ms per t'e Cupertino unicipal Code,Section
9.18.
���
/ ..ate /
0 OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I ant exempt from the Contractor's License Law for one of All roofs shall he inspected prior to any rooting material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the properly,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered fur sale(Sec:7044,
Business&Professions Code) Signature of Appliamt: Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ,\l.l.ROOF COVERINGS To BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MA'I'F:RL\LS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Ileallh&Safety Code.Sections 25505.25533.and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for b}, compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code.Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,1 shall maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's I leallh&Safety Cod tL Sectio s 25505,255 3,and 25534.
Compensation laws of California, If.after making this certificate of exemption,I
36
/CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097•Civ C.)
to building construction,anil hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned properly for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and Will comply ,\RCII I"I'FCI"S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. I understand my plans shall be used as public records.
Signature Date Licensed Professional
CITY OF CUPERTINO
49/
' FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 21431 Vai Ave DATE: 10/30/2012 REVIEWED BY: SEAN
tr'{. APN: BP#: 'VALUATION: $26,000
*PERMIT TYPE:. Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY PENIAMATION
SFD or Duplex • SOLAR-RES
USE: PERMEI"EYPE:
WORK INSTALLATION OF ROOF MOUNTED SOLAR SYSTEM WITH (19) MODULES (4.56 KW).
SCOPE
4
Mcclr. Plan Check Plumb. Plan Cheek Elec.Plan Check
Mech. Permit Fee: Plumb.Permit Fee: Elec. Permit Fee:
Other Mech.Insp. Other Plumb Insp. Other Elec. Imp. I I
Mech.Insp.Fee: Plumb. hop.Fee: Elec.Lrsp, Fee:
NOTE: This estimate does not include fees due to other Departments(i.e. Planning, Public Works, Fire.Sanitary Sewer District,School
District,etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'I info.
FEE ITEMS fFee Resolution 11-053 ER: 71/112) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 1 #} Alternative Energy System
Suppl. PC Fee: 0 Reg. 0 OT 0.0j hrs $0.00 $219.00 IPHOTOI'RES Photovoltaic System
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee:Q Reg. 0 OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Construction Tax:
Administrative Fee: 0
Work Without Permit? 0 Yes 0 No $0.00 0
Advanced Planning Fee: $0.00 Select a Non-Residential 0
Building or Structure 0
Travel Documentation Fees: i
Strong Motion Fee: IBSEISMJCR $2.60 Select an Administrative Item
Bldg Stds Commission Fee: /BCBSC $2.00
SUBTOTALS: $4.60 $219.00 TOTAL FEE: $223.60
Revised: 10/01/2012