15120003 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19811 PRICE AVE CONTRACTOR:THE SOLAR COMPANY, PERMIT NO:15120003
INC
OWNER'S NAME: ADAM JOEL F AND SHARON M TRUSTEE 20861 WILBEAM AVE STE 1 DATE ISSUED:12/01/2015
OWNER'S PHONE: 4084720451 CASTRO VALLEY,CA 94546 PHONE NO:(510)214-9005
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
INSTALL 15 ROOF TOP,FLUSH MOUNTED PV MODULES
License Class Lic.# { (4.9KW)
Contractor , (1 (AOyr jL 0 Date `12 — t
I hereby affirm that l 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:$20000
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;36905017A0 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 WO T STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 18 OF PE SUANCE 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 , - S FRO INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgmei
costs,and expenses hick in accrue against said City in consequence of the Issued b
granting of this per itio ally,the applicant understands and will comply
with all non-poi t o gulat n perthe Cupertino Municipal Code,Sectio
.9.18.
` RE-ROOFS:
Signature Date All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,l agree to remove all new materials for
inspection.
13OWNER-BUILDERDECLARATION
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 ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,or my employees1with 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 25 t2lndore or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I n� devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined b t euality Management District I
performance of the work for which this permit is issued. will maintain compliance wit t ecipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Se 'onsnd 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized agent: Date:
permit is issued. f -
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 9M am=
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO, CA 95014-3255
CUPERTIM0 (408)777-3228 -!FAX(408)777-3333-building oupetno.orct
PROJECT ADDRESS APN R l
OWNERIWIM - PHO E`
aa
l I iCj ''1_C)Lj } E-MAIL
STREET'ADDRESS � � I CIT , STA ZIP t h f�jL i(/ \ FAX
COh?ACT NAME n `��1 j�f E.1 0.IL
PHONE
STREET ADDRESS CITY,STATE,ZIP FAX
❑ O1V"ER ❑ OP:LNM-BUIL DER ❑ OWN R AGENT ❑ CONTRACTOR ❑CONTRACTOR AGF Tr ❑ ARM=CT ❑ENGINEER ❑ DEVELOPER ❑inNANT
CONTRACTOR NA1%4E LICENSE ALUh BER ( �' LICENSE TYPEJL,j ( BUS.LIC R
"I I
COMPANY NAME 9-jG 4{ E-MAIL I FAX
-=
STREET ADDRESS ( CITY,STATE,ZIP PHONE
ARCIIITECT/ENGINEER N4.>,E LICENSE NLT473ER BUS.LIC R
COMPANY NAME B-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑ SFD or Duplex ❑ Multi-Family PROJECT IN WILDLANLD PROJECT IN
STRUCTURE: ❑ COMMerCial URBAN INTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ No
rF4
ANELS ❑ ELECTRIC VEHICLE MkRGING S I ATION ❑ SOLAR V jATEIt I'EATING ❑ OTHER: ``
PAXELS: NUMBEROFPANELS/UNITS: KILOWATTS(COMMERCIAL ONLLY): ~�r/� / TOTAL VALUATION: i' �N OF WORK
15
By my signature below,I certify to each o,the fo log ing: m the property owner or authorized agent to act on the property s behalf. I have read this
application and the information I ha�e r i ct. I have read the Description of Work and verity:tis accurate. I agree to comply vdith all applicable local
ordinances and state laws relating to wld g c'on. I authorize representatives of Cupertino to enter the abo1e-denffiedproperty for inspection purposes.
S imature ofApplicanUAgent: Data:
Sup L£ NT II\'FORMATION REQTJIREDMm
t r
UWE
OYOI2fiH1r�0I7IaTER ��
`� XPRES "
low IN
PT/,4pp 2011.doc revised 03/16111
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 19811 PRICE AVE TDATE: 12/0112015 REVIEWED BY: MELISSA
APN: 369 05 017 BP#: 'EVALUATION: 1$20,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE: SOLAR-RES
WORK INSTALL 15 ROOF TOP FLUSH MOUNTED PV MODULES 4.9K
SCOPE
Check f f F... illy I Ch,zc.
'ff 7 'ji�j°. F ;'jS,f 1<.T, � f.<.. t:. t`., I {,`,p,.
Li Lj
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 greliminar information available and are onLy an estimate. Contact the De t or addn'1 into.
FEE ITEMS (Fee Resolution 11-053 E& 7111131 FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 1 # Alternative Energy System
Suppl. PC Fee: (F) Reg. 0 OT 0,0 hrs $0.00 $236.0071PHOTOI-S Photovoltaic System
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Feer Reg. OT Q p hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
El
Work Without Permit? 0 Yes
D No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential 0
p } - - Building or Structure
17<,vef 1.3f%cfemermaF ion Fe.!S. -
Strom Motion Fee: IBSEISMICR $2.60 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.001 1
SI7BTOTALS:z: $3.60 $236.00 . 1,0
Revised:
$239.60
,
Revised: 10/01/2015