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B-2016-2104 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2104 10145 SCENIC BLVD CUPERTINO,CA 95014-2724(357 09 076) PROVOLTZ INC CAMPBELL,CA 95008 OWNER'S NAME: HARJONO TIKNO AND ERNIE TRUSTEE DATE ISSUED:06/10/2016 I OWNER'S PHONE:408-391-2204 PHONE NO:(408)796-4450 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class C-46 Lic.#919207 X BLDG —ELECT _PLUMB Contractor PROVOLTZ INC Date 11/30/2016 — I hereby affirm that I am licensed under the provisions of Chapter 9(commencing — —MECH X RESIDENTIAL— COMMERCIAL with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. JOB DESCRIPTION: N 13 PANEL ROOF-MOUNTED PV SYSTEM(4.49 KW) I hereby affirm under penalty of perjury one of the following two declarations: 1. 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 performance of the work for which this permit is issued. 2. I have and will maintain Worker's Compensation Insurance,as provided for by rii Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$24500.00 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 APN Number: Occupancy Type: and state laws relating to building construction,and hereby authorize 357 09 076 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,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature./��/ Date 6/10/2016 Issued by:Abby Ayende (�na� Date:06/10/2016 ll�(��JJ�� OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License'Law for one of the RE-ROOFS: following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is 1. I,as owner of the property,or my employees with wages'as their sole installed without first obtaining an inspection,I agree to remove all new materials for compensation,will do the work,and the structure is not intended or offered for inspection. sale(Sec.7044,Business&Professions Code) 2. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant: contractors to construct the project(Sec.7044,Business&Professions Code). Date:6/10/2016 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1. 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 performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE 2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the 3. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous shall not employ any person in any manner so as to become subject to the material. Additionally,should I use equipment or devices which emit hazardous I air contaminants as defined by the Bay Area Air Quality Management District I Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 25534. Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agent: APPLICANT CERTIFICATION Date:6/10/2016 1 certify that I have read this application and state that the above information is CONSTRUCTION LENDING NDINAGENCY correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.) to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name to save indemnify and keep harmless the City of Cupertino against liabilities, judgments,costs,and expenses which may accrue against said City in Lender's Address consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION Code,Section 9.18. 1 understand my plans shall be used as public records. Signature Date 6/10/2016 Licensed Professional 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)cupert!no.or( +CUPERTINO 'Z10 PROJECT ADDRESS �C epi Q f V a 7APN# b-4 _ ` 1 �J _ i 1T(P OWNERNAME (J V PHONE)��1�^ f^�c/JlD� E-MAIL STREET ADDRESSto l S ��CL Oki CJS CCA STATE ' P C^ q S_0 f i f FAX CONTACT NAM PHONE 14 ( E-MAIL , t��na�� re q� _&k3.-Z77c� I"l uc��` Taco ,ccs-�, STREET ADDRESS CITY,STATE ZI FAX 5F13 ®�� SF) SG.} t, r17 �1 614 9 S F ❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACTOR W'CONTRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME 5�f C h LICENSE N9MBC M CGV� R LICENSE�PE BUS.LIC# COMPANY NAME ( E-MAIL FAX J U �'� STREET ADDRESS CITY,STATE ZIP PHONE 5c, cumk-f� ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS / CITY,STATE,ZIP PHONE USE OF E� �rD Gr Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN STRUCTURE: ❑ CommeIcial URBAN INTERFACE AREA ❑ Yes 21/'NO FLOOD ZONE ❑ Yes 2 No LAR PANELS I ❑ ELECTRIC VEHICLE CHARGING STATION ❑ SOLAR WATER HEATING ❑ OTHER: FOR SOLAR PANELS: NUMBER OF PANELS/UNITS: `3 KILOWATTS(COMMERCIAL ONLY): TOTAL VALUATION: 2 q/J(^� DESCRIPTION OF WORK Ktj v o'5 Ix a r �� -f c�J t RECEIVED BY ? By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner'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 building construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: '/' 1 � Date: /lU/ 2 C' SUPPLEMENTAL INFORMATION REQUIRED ' OFFICE USE ONLY OVER-THE COUNTER`- r" ❑ EXPRESS STANDARD 4a ❑ LARGE': 0.=MAiO PVApp_2011.doc revised 03116111