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15120104 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20819 FARGO DR CONTRACTOR:PV GURU INC PERMIT NO: 15120104 OWNER'S NAME: MILLER RONALD S TRUSTEE 144417TH ST STE 2 DATE ISSUED:12/11/2015 OWNS 'S PHONE: 4084315935 SANTA MONICA,CA 90404 PHONE NO:(714)866-7979 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL ., INSTALL(N)ROOFTOP MOUNTED SOLAR PV-16 PANELS License Class . Lic.It 3 3 7'--�> (( (4.32 KW) Date C� Contractor V j " 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:$12000. 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:32630130.00 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 INSP ION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, ( costs,and expenses which may accrue against said City in consequence of the ( Date: J` , granting of this permit. Additionally,the applicant understands and will comply Issued by: with all non-point source regulations per t Cupertino Municipal Code,Section 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,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: ALL 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) 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 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 Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent 1 Date: : permit is issued. I certify that in the performance of the work for which this permit is issued,I shallo 1 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(See.3097,Civ CJ 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 Man COMMUNITY DEVELOPIJiENT DEPARtMENT• BUILDING DIVISION 0-A 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERT6 O (408)777-3228• FAX(408)777-3333-buildina ..cupertino.org PROJECT ADDRESS t APN �. OWIviRNA?`IE ( PHON yg�L ���'y� � -MAIL � aSm ' l G'f GF STREET ADDRESSCITY, STATE,ZIP J FAX CONTACT NAME. t �jt✓f Ci Y� PHOI _ L 1® E-MAIL G L)I&OW STREET ADDRESS / -/ YLI �� CITY,S ATE,ZIP q® FAX ❑ ROR ARCHCT ❑EGiTFR ❑ DEVELOPER E3 TENANT M ❑ OW11rR-BUILDER OR,7tAGENT CO� R CONTRACTORNAMEypn. LICENSE NUMBER LICENSE TYPE BUc r n COA.PANY NNAM$ p E-MAIL I FAX ! 0ru Ca A if ,, ST & V .REST ADDRESS CITY.STATE,ZIP HONE 0 (-1+" `� u7�J I rl t GC' at ti q ARCHITECT,SNGIN'EERNAALE LICENSE NUMBER I BUS.LIC COMPANY NAMX E-MAIL 4 FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑ SFD'or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes ❑ NO FLOOD ZONE 0 Yes ❑ NO SOLAR PANELS ❑ ELECTRIC VEHICLE CF'ARGnvG STATION ❑ SOLAR WATER HEATING ❑ OTHER: FOR SOLAR PIXELS NUMBER OF PAN'ELSAANITS: �� KILOWATTS{COMMERCIAL ONL10: � �� �I�) TOTAL VALUATION: o 6 DESCRIPTION OF WORK lv� l 2 By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property o%per's behalf. I have read this application and the information I have provided 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 relating to b ildmg c trucfon. I au* rize epresentatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: 12- 15 SUPPLEMENTAL O ATIOi\t REQUIRED - �:��O VER�THJ vCOIIIt"�'�lt IMFxSs a ,� _. ''N GN `.�.�.� Pi14yp 2011.doc revised 03/16/11 t CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 20819 Fargo Dr DATE: 12/11/2015 REVIEWED BY: PAUL APN: 326 30 130 BP#: *VALUATION: $12,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY SFD or Duplex PENTAMATION USE: PERMIT TYPE: SOLAR-RES WORK Install N rooftop mounted solar PV- 16 Panels 4.32 kw SCOPE 77 t {{ 'F g n r €ff iiL,'?"�} st"I i P,:Sr'.'. �l:s.t.'3'JZ 3s':S,•'3. l i. 1'.;C'. }}fe z:yo-.'1'. �.. •,.5 ii f "E. t f .:i:. NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). These,fees are based on the preliminar inormation available and are only an estimate. Contact the De t or addn'l info. FEE ITEMS (Fee Resolution 11-053 Elf. 711113,) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 L_L_j # Alternative Energy System Suppl. PC Feer •= Reg. 0 OT 0.0 hrs $0.00 $236.00 1PHoT0vRES Photovoltaic System PME Plan Check: $0.00 Permit Fee: If $0.00 Suppl. Insp. Feer Reg. 0 OT0 0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 c:11On TfTN" idininisf alive l eel- 0 Work Without Permit? Yes No $0.00 Advanced Planning Fee: $0.00 Select a Non-Residential Building or Structure 0 Strong Motion Fee IBSEISMICR $1.56 Select an Administrative Item Bldg;Stds Commission Fee: IBCBSC $1.00 SVBT©TAL,S $2.56 $236.00 „° TOTAL FES $238.56 Revised: 10/01/2015