B-2016-1233CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: H-2016-1233
10010 CARMEN RD CUPERTINO, CA 95014-1040 (326 50 079) (PETERSEN-DEAN
INC)
FREMONT, CA 94538
OWNER'S NAME: BI-IATT PATAN3ALI AND RAU IYOTI TRUSTEE DATE ISSUED: 01/20/2016
OWNER'S PHONE: - PRONENO:
License Class Lie. #C I'{
t
Contractor ( PETERSEN-DEAN INC ) Date 0 1 /Z 0 A
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.
eby affirm under penalty of perjury one of the following two declarations:
1. 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.
2. 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 permit is issued.
APPLICANT CERTIFICATION
certify that I have read this application and state that the above
nformation is correct. I agree to comply with all city and county
rrdinances and state laws relating to building construction, and hereby
mthorize representatives of this city to enter upon the above mentioned
rroperty for Inspection purposes. (We) agree to save indemnify and keep
)armless the City of Cupertino against liabilities, Judgments, costs, and
)xpenses which may accrue against said City in consequence of the
)ranting of this permit. Additionally, the applicant understands and will
:imply with alLnon-point source regulations per the Cupertino Municipal
:ode, Section 9.18. E
�Z o
Date
16
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
1. 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)
z. I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
1. 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.
z. 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 permit is issued.
a. 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 subj ect to the
Worker's Compensation laws of California. If, after making this certificate of
exemption, I become subject to the Worker's Compensation provisions of the
Labor Cade, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
APPLICANT CERTIFICATION
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, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant
understands and will comply with all non -point source regulations per the
Cupertino Municipal Code, Section 9.18.
BUILDING PERMIT INFO:
X BLDG ELECT —PLUMB
_ MECH X RESIDENTIAL _ COMMERCIAL
DESCRIPTION:
ALL 23 ROOF TOP, FLUSH MOUNTED PV MODULES (6.44 KW)
Ft Floor Area: I Valuation:$30053.00
APN Number: Occupancy Type:
326 50 079
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS-FR-OM7G.&ST CALLED INSPECTION.
RF ROOFS:
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.
Signature
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California IIealth & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505, 25533, and 25534.
Owner or authorized agent: d
v
Date: n!1 LL
1 W 14ONSTRUCTION WNDING AGENCY
I hereby affirm that there is a construction lending agency for the performance
of work's for which this permit is Issued (Sec. 3097, Cie C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
Date
CUPERTINO
ALTERNATIVE ENERGY PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3265
(408) 777-3228 • FAX (408) 777-3333 • buiIdingn0 Cupertlno.Orq
7,-Tc(lo 33
PROJECT ADDRE S APN S Z 6 i• J C/— [/
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OWNERNAME PAT MATT I
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FAX
CONTACT NAME
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STREET ADDRESS
CITY, STATE, ZIP
FAX
❑ OWNER ❑ OWNER-BUB.DBR ❑ ONNERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACI'ORNAME FaTee-SeN De�.P
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COMPANY NAME Ttj�A��
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CITYASw E 2R� C �q 9 / a
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ARCH T ECT/ENGTNEER NAME
LICENSE NUMBER
BUS. LIC n
COMPANY NAME
E-MAIL
FAX
STREET ADDRESSES....////
CITY, STATE, ZIP
PHONE
USE OF IqS SFDor Duplex ❑ Multi -Family
PROJECT IN MIDLAND
PROTECT IN —_-�
STRUCTURE. /❑-OmmeiClRl S t e
URBAN TNTEAFACE AREA ❑ Yes � NO
FLOOD ZONE ❑ Yes �, NO
SOLAR PANELS_
❑ ELECTRIC VEHICLE CNaRCING STATION
ElSOLAR ATER HEATING
❑ OTHER:
FOR SOLAR PANELS: NUMBER OF PANELSM'ITS: %S KILOWATTS (COMMERCIAL ONLY): (.q�
TOTAL VALUATJON �r)! V 93 v
DESCRIPTION OF WORK( aQ A 6�.'l� ( eD
Vr 1
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V- LoWA-r-T
MENEM
By my signature below, I certify to each of the following: I am the property owner or authorized anent to act on the property tnva2V*teToalf. I have read this
application and the information I have provided is correct, 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 bu' i cc traction. thorize representatives of Cupertino to enter the abov/g-identified%roperty for inspection purposes.
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Signature of ApplicenUAgent: Date: Z 0/ I
SUPPL QENTAL INFORMATION REQUIRED
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PI/App_2011.doc revised 03/16/11
-- CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
10010 CARMEN RD DATE: 01/20/2016
REVIEWED BY: MELISSA
imADDRESS:
APN: 326 50 079 BP#: B-2016-1233
*VALUATION: $30,053
VERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY
SFD or Duplex
PENTAMATION
SOLAR -RE
USE:
PERMIT TYPE:
WORK
INSTALL 23 ROOF TOP FLUSH MOUNTED PV MODULES 6.44 K
SCOPE
,7ficla. Plan C'he", 1'lu�ub. PlavCheck JCIe(_ 11/on Clu cd
Ikck Fermi€ Fse: Plumb. P�jrid hec_ dile<. .farr`ui 1"
ETChher .�dlvA. Irnp. ochzr Ph"nh Irr/;, O;txr 5,'rc- Insp.
1ei:1j. ?r1sn, I,, PhvnbJrup. Ph.�': Elec. insp.
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
bhM,t ntr. 1. Thew faac .,, hnmd no th, nrn/iniinon> in formation awdlahle and are only on estin¢ote. Contact the Dent for told n'I into.
FEE ITEMS (Fee Resolution 11-053.(�&_7/WY)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
0 # Alternative Energy System
$236.00 imoy'omE's Photovoltaic System
Suppl, PC Fee: (E) Reg. 0 OT
0.0 1
his
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee:(E) Reg. 0
OT
0,0
lus
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
onsu 11" C �haft TQY:
Aehx,111Nlralnv Fee:
Q)
Work Without Permit? 0 Yes Q) No
$0.00
Advanced Planing Fee.,
$0.00
Select a Non -Residential
Building or Structure
G
a
C"eel Liacuiiazrrtrxl#ora fees:
Strong Motion Fee:
t 13SEISMICR
$3.91
Select an Administrative Item
Bldg, Sids Commission Fee: IBCBSC
$2.00
> BTO ALs: -
$5.91
$236.00
T TAY� E
$241.91
Revised: 01/01/2016