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15100203 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22287 STEVENS CREEK BLVD CONTRACTOR:�SOLARCITY PERMIT NO: 15100203 OWNER'S NAME: KAZEMI NASROLLAH AND NAHID TRUSTEE 3055 CLEARVIE14V WAY DATE ISSUED: 10/26/2015 OWNER'S PHONE: 4087779998 SAN MATEO,C ' 94402 PHONE NO:(650)638-1028 F6 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ INSTALLATION 49 ROOFTOP FLUSH MOUNTED SOLAR PANEL License Class 00 (12.48 KW) Contractor ®lav j t Date �C I hereby affirm that I am license 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: Sq.Ft Floor Area Valuation:$27500 �. I have and will maintain a certificate of consent to self-insure for Worker's t Compensation,as provided for by Section 3700 of the Labor Code,for the APN Number:3250034.00 Occupancy Type: performance of the work for which this permit is issued. 2. 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 permit is issued. PERMIT EXPIRES IF WORK IS NOT STARTED APPLICANT CERTIFICATION WITHINI 180 DAYS OF PERMIT ISSUANCE OR I certify that I have read this application and state that the above information is 18.0 DAY ROM LAST CALLED INSPECTION. 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 Issued by: Date: 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. Additi ally, applicant understands and will comply with RE-ROOFS all non-point source regulatio per Cupertino Municipal Code,Section 9.18. . All roofs shall be inspected prior to any roofing material being installed.If a roof is Signature r Date101J_jC,4i_5 installed without f4st obtaining an inspection,I agree to remove all new materials for $` inspection. ® OWNER-BUILDER DECLARATION Signature of Appliant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER the following two reasons: 1. I,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 HAZARDOUS MATERIALS DISCLOSURE sale(Sec.7044,Business&Professions Code) I have read the hazardous materials requirements under Chapter 6.95 of the 2. I,as owner of the property,am exclusively contracting with licensed contractors to California Health I&Safety Code,Sections 25505,25533,and 25534. Iwill maintain construct the project(Sec.7044,Business&Professions Code). compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Safety Code,Secton 25532(a)should I store or handle hazardous material. I hereby affirm under penalty of perjury one of the following three declarations: Additionally,shoi ild I use equipment or devices which emit hazardous air 1. I have and will maintain a Certificate of Consent to self-insure for Worker's contaminants as tt eti ed by the Bay Area Air Quality Management District I will Compensation,as provided for by Section 3700 of the Labor Code,for the maintain complia with t e Cupertino Municipal Code,Chapter 9.12 and the performance of the work for which this permit is issued. Health&Safety ode,S 'ons 25505,25533,and 25534. r 2. I have and will maintain Worker's Compensation Insurance,as provided for by Owner o ent: i Section 3700 of the Labor Code,for the performance of the work for which this Date: 10/2—& ( I S permit is issued. 3. I certify that in the performance of the work for which this permit is issued,I shall i CONSTRUCTION LENDING AGENCY 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 I hereby affirm that there is a construction lending agency for the performance of work's become subject to the Worker's Compensation provisions of the Labor Code,I for which this permit is issued(See..3097,Civ C.) Lender's Name 1 must forthwith comply with such provisions or this permit shall be deemed revoked. Lender's Address] APPLICANT CERTIFICATION ARCHITECT'S DECLARATION I certify that I have read this application and state that the above information is I understand my plj s shall be used as public records. correct.I agree to comply with all city and county ordinances and state laws relating II to building construction,and hereby authorize representatives of this city to enter Licensed Professi�nal upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, I costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. I Signature Date i i I i i ALTERNATIVE ENERGY PERMIT P ICA AE yy��}#r �^ pq y+� L bt T L 1 1.I t'Y�c3 - ...1 .'........4 ` `L,...__...,$ .'T =^ aQ` ��--- i PROJECT ADDRESS } i OWNERNAMELa. �(' � i PC P -lqqq t, I E-MAIL — STREET ADDRESS _ 1 �� 10a� CITY,STATE,ZIP 0 , e j ir+`I c, I o t Ll FAX - 1 1.. _ CONTACT NAME PHONE I. E-MA1L Marjan Javanmard 650.4771'6430 mjavanmard@solarcity.com STREET ADDRESS 391 Foster City Blvd CITY,STATE,ZIP Foster City, CA 94404 FAX ❑OWNER ❑ DOWNFR-BUILDER ElOWNER AGENT ElCONTRACTOR ®CONTRACTOR AGENT ElARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME SolarCi{y+Corporation LICENSENUMBER.88810, LtCENSETYPEC10 BUS.LIck28340 COMPANY NAME SollarCittssyLColsrporation E-MAIL m�((JJavanm`ae id@solarolty.com FAX vU STREET ADDRESS 391 Foster City Blvd Foster City, CA 94404CITY,STATE,ZIP PH 0'FE650.477.6430 ARCHITECTIENGINEER NAME LICENSE NUMBER BUS.LIC COMPANY NAME E-MAIL FAX i STREET ADDRESS CITY,STATE,ZIP PHONE USE OF SFD Or Duplex El Multi-Family PROJECT N WILDLAND PROJECT IN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ es ❑ No FLOOD ZONE ❑ Yes ❑ NO SOLAR PANELS ❑ ELECTRIC VEHICLE CHARGING STATION ❑ SOLAR WATE. R HEATING ❑ OTHER: FOR SOLAR PANELS: NUMBER OF PANELS/UNITS: KILOWATTS(COMMERCIAL ONO): T VAL VALIDATION DESCRIPTION OF WORK i Installation �k ) rooftop flush mounted t olar panel Cg,-�(IkW I RECEIVED BY'` 7� By my signature below,I certify to each of the following: I am the ropeI veer or authorized age t to act on the property owner's f. I have read this application and the information I have provided is correct. I hav ead the scription of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state Iaws relating to building construction. I atorze resentatives of Cupertino tai enter the above-identifi property fo inspection purposes. J Signature of ApplicantlAgent: `LL� Date: SUPPLEMENT � INFORMATION RF Qt7 Rl D. OrFICE USE ONLY ❑ OVER-TTIE-COUNTER ❑ EXPRESS _. U w ❑ STANDARD El U LARGE i 4 ❑ MAJOR PVApp 2011.doc revised 03/16111 i i I CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 22287 Stevens Creek Blvd DATE: 10/2 /2015 REVIEWED BY: Phuong APN: 326-50-076 BP#: *VALUATION: 1$27,500 —� *PERMIT TYPE: Building Permit PLAN CHECK TYPE k Alteration/ Repair PRIMARY SFD or Duplex PENTAMATION USE: P PERMIT TYPE: SOLAR-RE WORK Installation 48 roofton flush mounted solar panel 12.48 KM SCOPE I ' j _i __ Mec h-Tian(,'he< !jtar,�%).flan{_,'12e k Ele.c. Alan Check llce'I,..I'ef'n:€r1=er: Fftrr7rr-.rc.rtntte<<: i Era:<".I'c->•tzitFc°F:: Oth f E� 1'it rri t')Iii'j;. t„}Lh {z Iec' hal.). Wech. hi t7. f°L-'f.': �37tfif7il. Irtr7� F'ee: /nZ p” NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . Thesefees are based on the prelhindina information available and are only an estimate. Contact the De t or addn'l info. FEE ITEMS(Fee Resolution 11-053 E . 7/1/13) FEE QTY/FEE 1 MISC ITEMS Plan Check Fee: $0.00 � # j Alternative Energy System Suppl.PC Fee: (j) Reg. 0 OT FOA hrs $0.00 $236.00] IPHOTOVRES Photovoltaic System PME Plan Check: $0,00 Permit Fee: $0.00 I Suppl.Insp.Fee: Reg. 0®T0.0 hrs $0.00 PME Unit Fee: $0.00 _ I PME Permit Fee: $0.00 (.7onstruction ?ix i ;t.c�tnr'��rsttcrta�r�Fec: Work Without Permit? 0 Yes (F) No $0.00 E Advanced Planning Fee: $0.00 Select a Non-Residential y q Travel 1)L>cLirrlGzntcrtt€?17 1-('c's. Building or Structure 04 4 Strong Motion Fee: IBSEISMICR $3.58 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $2.00 j SITBTOTALS: $5.58 .$236.0 TOTAL FEE. $241.58 Revised: 10/01/2015 i