B-2016-1493, Permit & ApplicationCITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR;
PERMIT NO: B-2016-1493
23655 OAK VALLEY RD CUPERTINO, CA 95014-6554 (342 56 007)
( ELITE ELECTRIC )
RIVERSIDE, CA 92509
OWNER'S NAME: KURPANEK GORDON
DATE ISSUED: 03/10/2016
OWNER'S PHONE: 408-893-9431
PRONE NO: 510-562-1I70
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class C=10 Lie. #418242
Contractor( ELITE ELECTRIC ) Date 03/10/2016
X BLDG —ELECT _PLUMB
X RESIDENTIAL COMMERCIAL
I hereby affirm that I am licensed ender the provisions of Chapter 9 (commencingMECH
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in fall farce and effect.
JOB DESCRIPTION:
INSTALL 20 ROOF TOP, FLUSH MOUNTED PV MODULES, 6.9kW
I hereby affirm under penalty of perjury one of the following two declarations:
r. 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.
OT2. 1 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
Sq. Ft Flnor Area;
Valuation: $7000.00
this permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and stale that the above
information is correct. I agree to comply with all city and county
APN Number:
Occupancy Type:
ordinances and state laws relating to building construction, and hereby
342 56 007
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
PERMIT EXPIRES IF WORK IS NOT STARTED
expenses which may accrue against said City in consequence of the
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally, the applicant understands and will
comply with all non -point source regulations per the Cupertino Municipal
180 DAYS FROM LAST ECTI0N.
Code, Section 9.18,
Issued by: ME
Signature — Date 03/10/2016
Date: 0 lA
OWNER -BUILDER DECLARATION
RE -ROOFS:
I hereby affirm that I am exempt from the Contractor's License Low for one of tine
All roofs shall be inspected prior to anyroofing material being installed. If a roof is
following two reasons:
installed without first obtaining an inspection, 1 agree to remove all new materials for
r. I, i s owner of the property, or my employees with wages as their sole
inspection.
compensation, will do the work, and the structure is not intended or offered
for sale (Sce.7044, Business & Professions Code)
Signature of Applicant:
2. I, as owner of the property, am exclusively contracting with licensed
Date: 03/10/2016
contractors toconstruct the project (Sec,7044, Business & Professions Code),
I hereby affirm tinder penalty of perjury one of tine following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1. 1 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
HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued.
I have read the hazardous materials requirements under Chapter' 6.95 of the
2. I have and will maintain Worker's Compensation Insurance, as provided for
California Health & Safety Code, Sections 25505, 25533, and 25534. twill
by Section 3700 of the Labor Code, for the performance of the work for which
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
this permit is issued.
Health & Safety Code, Section 25532(a) should I store or hmadle hazardous
3. 1 certify that in the performance of the work for which this permit is issued, I
material. Additionally, should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as (a become subject to the
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
Worker's Compensation laws of California, If, after making this certificate of
the Health & Safety Code, Seeti ns 2 S 5,25533, and 25534.
exemption, I become subject to the Worker's Compensation provisions of the
Labor Code, I must forthwith comply with such provisions or this permit shall
Owner or authorized agent:
be deemed revoked. ..
Date: 0311012016
APPLICANT CERTIFICATION
CONSTRUCT- DINGAGENCY
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
correct. I agree to comply with all city and county ordinances and state laws
of work's for which this permit Is issued (Sec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
Lender's Name
to enter upon the above mentioned property for Inspection purposes. (We) agree
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Address
judgments, casts, and expenses which may accrue against said City In
consequence of the granting of this permit. Additionally, the applicant
ARCHITECT'S DECLARATION
understands and will comply with all non -point source regulations per the
I understand my plans shall be used as public records.
Cupertino Municipal Cade, Section 9.18.
Licensed
Professional
Signature Date 03/10/2016
CUPERTINO
ALTERNATIVE ENERGY PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777.3333 • buildirroacucertino.org
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USE Of FD OT Duplex ❑ Multi -Family PROJECT W WILDLAND
PROJECT IN
STTRUUCCTUKE: ❑ COmmerG'al URBAN INTERFACE AREA ❑ Yes ❑ No
FLOOD ZONE ❑ Yes ❑ NO
M SOLAR PANELS
❑ ELECTRIC VEHICLE CH4ROINO STATION
❑ SOLAR WATER IffAT[N6
❑ OTHER:
FOR SOLAR PANELS: NUMBER OF PANELSMJITS: KILOWATTS(COMhIERCIAL ONL1�:
TOTAL VALUATION:gi'i�
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DESCRIPTION OF WORK J `/U ^
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By my signature below, I certify to each of the fo !awing: I am the property owner orauthorized agent to act on the property owier's behalf. I have read this
application and the information I have prov) IdeVA 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� ins us o . I zu lize representatives of Cupertino to enter the above -identified roperty for inspection purposes.
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SlgnatureofApliplicanr/Agent: - Iel
Date:—%
SUPPL MENTAL INFORMATION REQUIRED
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