15120166 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10665 CULBERTSON DR CONTRACTOR:CLEAN SOLAR PERMIT NO: 15120166
OWNER'S NAME: LAM TERENCE T AND CHRISTINE F 1445 KOLL CIR STE 109 DATE ISSUED: 12/17/2015
OWNER'S PHONE: 4088872118 SAN JOSE,CA 95112 PHONE NO:(408)217-8876
10 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
INSTALL(N)ROOFTOP:MOUNTED SOLAR PV-17 PANELS.
License Class 0 �f(J Li.,# �fCJ (5.36KW)
Contractor � �,y� �
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
erformance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$24748
ave 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:37536031.00 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
correct.I agree to comply with all city and county ordinances 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 D YS FROM LAST CALLED INSPEC IO
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 lations per Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Sig to 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
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL L ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 offered for sale(Sec.7044,
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Parofessions 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 Cuperto Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Co ,Sect�ons,2550 533, d 2 534.
It 74Section 3700 of the Labor Code,for the performance of the work for which this Owner or authoriz ag Datet
permit is issued.
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
CONSTRUCTION LENDING AGENCY
Compensation laws of California. If,'after making this certificate of exemption,I
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 ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
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 05014-3255
CISP RTtNO (408)777-3228• FAX(408)777-3333.,buildinge.cupErtino.org
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PROJECT ADDRESS APN n .'36 051
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CONTACT NAME �� HONE E-hLb IL
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01\'NER ❑ O1VAcR-BUII..DER ❑
OMNER AGENT 19QON7RACTOR ❑coi\TRACTORAGEI\T El ARC=1 1CT El ENGINEER ❑ DEVELOPER ❑TEI ANT
CONTR0.CTORNAZ 4 UCENS L74B LIC 'SE E 9y __ BUS.LIC
COMPANYNAME
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STREET ADD t S CI STATE,ZIP _ PHOh
ARCHITECT/ENGINEER NAI`4E I LICENSE NUMBER I BUS.LIC m
COMPANY NAME E-MAIL FAX
STREET ADDRESS I CITY,STATE,ZIP PHONE
USE OF PI<5FD or Duplex p Multi-Family PROJECT IN WILDLAND PROJECT IN
STRUCTURE: ❑ Commercial URBAN INTERFACE AREA Yes ❑.NO FLOOD ZONE ❑ Yes 7 NO
AR PANELS I] ELECTRIC VEHICLE CHARGING STATION ❑ SOLAR WATERI'EATING El OTHER...
FOR SOLAR PANELS: NUMBER'OF PANELSlUNITS: KILOWATTS(COMMERCIAL ONLl'): TOTAL VALUATIC ;
DESCRIPTION OF WORK `C
ti ..
RECETSEDBh . 1
By my signature below,I certify to each of the folloN me: I am the property owner or authorized agent to act on the property o-\mer's behalf. I have read this
application and the information I have provided i orrect. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state la\vs r o building co ' . I autho 'z representatives of Cupertino to enter the above-ide t+i'fiied property for inspection purposes.
S ignature.of Applicant gen.
•• + Date:
SU LE_ \T L I1\1FORMATION REQUIRED o FJc rsE o.zY
0-5
Sam
_
Cl_EY.PI2ESS
PT1App_2011.doc revised 03/16111
CITY OF CUPERTINO �` '
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10665.Culberston Dr DATE: 12117/2015 REVIEWED BY: PAUL
166 .
AP
N: 375 36 031 BP#: 'VALUATION: $24,748
'PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition
PRIMARY SFD or Duplex PENTAMATION SOLAR-RES
USE: PERMIT TYPE:
WORK Install N rooftop mounted solar PV- 17 Panels 5.36K
SCOPE
.a C;i. f y:f.'F?c'€•;, t .d :,'1. t?a_, t.,le'6� .. f X' £-ex
s3`s; £. S .f..
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 prelimina information available and are onl an estimate. Contact the Dept./or addn'l into.
FEE ITEMS(Fee Resolution 11-053 F�: 7 1 13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0,00 1 # Alternative Energy System
Suppl.PC Fee: Reg. 0 OT 0.0 hrs $0.00 $236.00 IPHOTovxES Photovoltaic System
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Fee:cEReg. Q OT p,Q hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
0
Fee"..
Work Without Permit? Yes ( No $0.00
Advanced.Planning Fee: $0.00 Select allon-Residential
Building or Structure 0
Strong Motion Fec: 1 BSEISMICR $3.22 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
SUBTOTALS: $4.22 $236,00 TOTAL FEE: ' $240.22
Revised: 10/01/2015