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15070206CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21971 COLUMBUS AVE CONTRACTOR: REC SOLAR, INC. PERMIT NO: 15070206 OWNER'S NAME: GREIF RICHARD K 775 FIERO IN STE 200 DATE ISSUED: 07/29/2015 OWNER'S PHONE: 4089960977 SAN LUIS OBISPO, CA 93401 PHONE NO: (888)657-6527 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL EJ COMMERCIAL �t License Class Lic. # �S'Ol `1 INSTALL 14 ROOF TOP, FLUSH MOUNTED PV PANELS (3.64 Contract Date Lg f KWI I h 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: $7600 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: 35614037.00 Occupancy Type: permit is issued. 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction, and hereby authorize representatives of this city to enter WITHIN 180 DAYS OF PERMIT ISSUANCE OR upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, 180 DAYS FR LLED INSPECTION. costs, and expenses which may accrue against said City in consequence of the Z granting of this permit. Additionally, the applicant understands and will comply ued by: Dat • / with all rion-point sourc regulations per the Cupertino Municipal Code, Section 9.18. RE -ROOFS: j *'� / I " �� l S 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: 1, as owner of the property, or my employees with wages as their sole compensation, ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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 I hereby affirm under penalty of perjury one of the following three California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will declarations: maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the I have and will maintain a Certificate of Consent to self -insure for Worker's Health & Safety Code, Section 25532(a) should I store or handle hazardous 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 Section 3700 of the Labor Code, for the performance of the work for this the Health & Safety Code, Sections 255 5, 25533, and 25534. 1 which permit is issued. . Owner or authorigent: �i Date: 9 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 Lender's Address 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, 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 CUPERTINO ALTERNATIVE ENERGY PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 •FAX (408) 777-3333 • building a(D,cupertino.orq PROJECT ADDRESS 1 � � � PT1APp2011.doc APN 0 j �3—+ / OWNERNAME_ ), C,\ CA� ` � `� PHONE // p �r`� l�o� -] E-MtlAIL I�� STREET ADDRESS s 1 4 �� C ® ®G� pVIA CITY, STATE, ZIP FAX )E-MAIL CONTACT NAME PHONE jb� 3P'� si.9 1 V{ STREET ADDRESS �% oo CITY, STATE, ZIP c w SW -ts-� I FAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME �� q % 1 _ LICENSE NUMBER p /J g; 6 v.(i LICENSE TYPEC _ l �i of BUS. LIC 4 COMPANY NAME 1 A r� ,,// r� E-MAIL FAX STREET ADDRESS 67 �j; ` I\ r% �(� 1� �,I�f CITY, STATE, ZIP / ,y o ' �g ,fid 3 i PHONE ARCHITECT/ENGINEERNAME LICENSE NUMBER BUS. LIC 4 COMPANY NAME &MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHOt\i I fl v USE OF ❑ SFD or Duplex ❑ Multi -Family STRUCTURE: ❑ CommeIcial PROJECT IN WILDLAND URBAN INTERFACE AREA ❑ Yes ❑ No PROJECT IN FLOOD ZONE ❑ Yes ❑ NO ❑ SOLAR PANELS ❑ ELECTRIC VEHICLE CHARGING STATION -7 ❑ SOLAR WATER HEATING ❑ OTHER: FOR SOLAR PAA'ELS: NUMBER OF PANELS/UN1TS: KILOWATTS (COMMERCIAL ONLY): TOTAL VALUATI DESCRIPTION OF WORK � q 4 ,� P� (� � - R _ r � Emm..Iv:-� By my signature below, I certify to each of the oilowing: I am the property owner or authorized agent to act on t owner's behalf. I have read this application and the information I have provi 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 relati gonsstruction. ' e representatives of Cupertino to enter the above-identi ed prope for/inspection purposes. Signature ofApplicanU pent: ll-Date:2�® SUPPLEMENTAL INFORMATION REQUIRED kr} �tbY� .,qt ij+✓�. 00 T Jif SRuAiiiw�'Y'L'liY�� 5 {LT1�rN:S.N�ASy; M 0iFY1>I"p �lyk1- revised 03/16/11 CITY OF CUPERTINO FEF FIgTTMATnR _RTTrr.nrivrr n1rX71rcrnXr Alech. Plan C'/seek. Plumb. Plan Check Elec. Plan Check dde<:lt. Permll Fee: I'lunib. Permir Fee: I . Permit fee: Otherillech. Imp. A/t?ch. In,sp. Fee: Other Plumb bap. Plumb. Insp, Fee: Other Flee. lisp. /Flee. Insp. Fee: • •u1.3. 1 ata caurnute cues not tnctuae fees aue to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School DWriet_ Pte.)_ Thoco fooc "_ ho ,t n., oz.. FEE ITEMS (Fee Resolution 11-053 E 7/1/13 ADDRESS: 21971 COLUMBUS AVE DATE: 07/29/2015 REVIEWED BY: MELISSA APN: 356 14 037 $0.00 *VALUATION: $7,600 Alternative Energy System 1PHOTOVRES Photovoltaic System Suppl. PC Fee: (D Reg. 0 OT 0.0 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: $0.00 PENTAMATION PERMIT TYPE. SOLAR -RE WORK INSTALL 14 ROOF TOP FLUSH MOUNTED PV PANELS 3.64 k SCOPE hrs Alech. Plan C'/seek. Plumb. Plan Check Elec. Plan Check dde<:lt. Permll Fee: I'lunib. Permir Fee: I . Permit fee: Otherillech. Imp. A/t?ch. In,sp. Fee: Other Plumb bap. Plumb. Insp, Fee: Other Flee. lisp. /Flee. Insp. Fee: • •u1.3. 1 ata caurnute cues not tnctuae fees aue to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School DWriet_ Pte.)_ Thoco fooc "_ ho ,t n., oz.. FEE ITEMS (Fee Resolution 11-053 E 7/1/13 FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 = # $236.00 Alternative Energy System 1PHOTOVRES Photovoltaic System Suppl. PC Fee: (D Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:(F) Reg. Cl OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 CW ion Tax: .11(hninisvr4.7five Fee: O G Work Without Permit? 0 Yes (j) No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure G 0 i Travel Documentation Fees: Strong Motion Fee: IBSEISMICR $0.99 1 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.001 :>SUBTO"PALS+' $1.99 $236.00 TOT FEE4. - $237.99 Revised: 07/02/2015