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15050031 (2) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20230 JOHN DR CONTRACTOR:PETERSEN-DEAN INC PERMIT NO: 15050031 OWNER'S NAME: GRUBBS WAYNE H AND CUNNINGHAM LINDS 7980 ENTERPRISE DR DATE ISSUED:05/06/2015 OWNER'S PHONE: 4088585314 NEWARK,CA 94560 PHONE NO:(510)494-9982 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL j II INSTALLATION OF ROOF MOUNTED SOLAR(24 License Class U— b G` Li,.# t' I / MODULES)(6.6 KW). Contractor r��-r�Ie'h C-L` Date k 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. 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. Sq.Ft Floor Area: Valuation:$30800 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 APN Number:36935004.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED I L correct.I agree to comply with all city and county ordinances and state laws relating WITFIIN 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 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ��——� granting of this permit. Additionally,the applicant understands and will comply Issued by:�� Date:' with all non-point source re tions per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature sC/� ---''J� Date All roofs shall be inspected prior to any roofing material being installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I,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 offered for sale(Sec.7044, Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 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 contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505 33,a>�5534. Section 3700 of the Labor Code,for the performance of the work for which this �- i 5' permit is issued. Owner or authorized agent: 4 Date: / 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 certificate of exemption,I CONSTRUCTION LENDING 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 deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION 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 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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'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-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9 18. Signature Date ALTERNATIVE ENERGY PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333•buildingC�cupertino.org CUPERTIMO PROJECT ADDRESS % i r + 35 OWNERNAME V`J i I. 1 ,Yf'A f 1� r PHONE L{� c -rjt s, E-MAIL STREET ADDRESS P 3 CITY,�ST\AATE,ZIP , CONTACT NAME •� �-U / \p PHONE �` 5—z lz s E-MAIL STREET ADDRESS (�✓� r s E C��STATE,,ZIP",_, /� f,t / (ti FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR *9�ZQNIRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NLICENSE NUMBER d LICENSE TYPE BUS.LIC# AME �\�� 'C/ ! _ E-MAIL FAX COMPANY NAME A-1� �� J ��` �✓U t lt< STREET ADDRESS lC J l� h A C i , CITY.STATE,ZIP /I. J��q PHONE P-- STREET ARCHITECT/ENGINEER NAME LICENSE NUMBER , `/ BUS.LIC# 10 COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF SFD or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN URBAN INTERFACE AREA ❑ Yes No FLOOD ZONE ❑ Yes No STRUCTURE: ❑ Commercial `SOLAR PANELS ❑ ELECTRIC VEHICLE CHARGING STATION ❑ SOLAR WATER HEATING ❑ OTHER: — FOR SOLAR PANELS. NUMBER OF PANELS/[JNITS: J KILOWATTS(COMMERCIAL ONLY): r D e TOTAL VALUATION: SO DESCRIPTION OF WORK RECEIVED BY By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building c struction. uthorize representatives of Cupertino to enter the abov en ifed`p�� eerty for inspection purposes. Signature of Applicant/Agent: -�� Date: �/ SUPPLEMENTAL INFORMATION REQUIREDY` a ORTHECOUN�ERfiaFr PVApp_2011.doc revised 03/16/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION WAPN: DDRESS: 20230 JOHN DR DATE: 05/06/2015 REVIEWED BY: SEAN BP#: 'VALUATION: $30,800 ^"PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex PENTAMATION SOLAR-RES USE: p PERMIT TYPE: i WORK INSTALLATION OF ROOF MOUNTED SOLAR 24 MODULES 6.6 kW). SCOPE Q t ..z T— )o'e, (�.I eckwrbPI .Alvm;£I�.:.�.c:,'" Xf,?,h.I„sr.Fee: Pear bt I,<p; F"e°: I?''Iec. r?t, Fee: NOTE:This estimate does not include fees due to of/:er Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . Theseees are based on the prelimina information available and are only an estimates Contact the Dept-for addn'l info. FEE ITEMS (Fee Resolution.11-053.Eff. 7/1 13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 = # Alternative Energy System Suppl.PC Fee: Q Reg. Q OT 0.0 hrs $0.00 $236.00 1PHOTOVRES I Photovoltaic System PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp.Fee-.0 Reg. Q OT O,Q hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Work Without Permit? 0 Yes No $0.00 E) Advanced Planning Fee: $0.00 Select a Non-Residential E) Building or Structure 0 Strong Motion Fee: IBSEISMICR $4.00 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $2.00 d TOTAL I+'�E 3'. $L $6.00 $236.0 42.00 SiTBTOTALS-' 0 Revised: 04/01/2015