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B-2016-2434 CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: CONTRACTOR: PERMIT NO:B-2016-2434 1224 RUPPELL PL CUPERTINO,CA 95014-5049(362 30 038) ENERGY REMODELING INC WOODLAND HILLS, CA 91367 OWNER'S NAME: NAKAMURA JERRY TRUSTEE&ETAL DATE ISSUED:08/01/2016 OWNER'S PHONE:408-225-1039 PHONE NO:(877)2454672 LICENSED CONTRACTOR'S DECLARXTION BUILDING PERMIT INFO: License Class CA Lic.#968844 ContractorENERGY REMODELING INC Date 12/31/2017 X BLDG ELECT _PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9(commencing —MECH X RESIDENTIAL_COMMERCLAL with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. JOB DESCRIPTION: I hereby affirm under penalty of perjury one of the following two declarations: (N)20-PANEL ROOF MOUNTED PV SYSTEM(5.2 KW) 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 "4....e of the work for which this permit is issued. 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. Sq.Ft Floor Area: Valuation:$20000.00 APPLICANT CERTIFICATION 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 362 30 038 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 Cupe ino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature Date 8/1/M6 Issued by:Abby Ayende i, Date:08/01/2016 O - DER DE LARAT N 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. 1,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 ofApplicant_ contractors to construct the project(Sec.7044,Business&Professions Code). Date:8/1/2016 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER s, 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 ofthe 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 s. 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 air contaminants as defined by the Bay Area Air Quality Management District L Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino M al Code,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 505, 53 and 25534. Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agen APPLICANT CERTIFICATION C Date:.8/1/2016 I certify that I have read this application and state that the above information is N TR TI N L A Y 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. Licensed Signature Date .8/1/2016 Professional ALTERNATIVE ENERGY PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 (408)777-3228 o FAX(408)777-3333•building(a.cupertino.org CUPERTINO PROJECT ADDRESS ,2r L/ p ® �an APN# 2(_1 - �)O J�3 ® (® 7 l�alic� P[i v I rJ(„EI �,J(J_ lJ " OWNERNAME �� ,V f PHONE E-MAIL STREET ADDRESS g�/ �(Jr✓//�i,��jj��®�1'�' CITY,.STATE,ZIP �1 " i � ' JFAX CONTACT NAME .*&j �� vLN� 1,A(0o PHONE � � s) �/u E-MAII °GJI�/�fA0�4)N/X 1 efn ISS/ STREET ADDRESS CITY,STATE,ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT 1514CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER. ❑TENANT CONTRACTOR NAME jp&C,,p 9 LICENSE NUMBER�Q e / LICENSE TYPE pg p BUS.LIC COMPANY NAME ,4400] Aj(4 E-MAIL Afev5e1�� /I/ ��J✓t®ed C/( FAX STREET ADDRESS CITY,STATE,ZIP ` PHONpj,, ARCHITECT/ENGINEER NAME I I V /C/✓1/ LICENSE NUMBER BUS.LIC# i AAr1—s3`a 44,9 0,---S14_ COMPANY NAME FAX STREET ADDRESS CITY,STATE,ZIP h AIE f�i� ipp � USE OF ❑ SFD Or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes FLOOD ZONE ❑ Yes ErNO OLAR PANELS ❑ ELECTRIC VEHICLE CHARGING STATION ❑ SOLAR WATERHEATING ❑ OTHER: FOR SOLAR PAXEZS: NUMBER OF PANELSIUNITS: -7,4) KILOWATTS(COMMERCIAL ONLY): TOTAL VALUATIO r DESCRIPTION OF WORK �" IV eo Cr On/ Pt/%ks 77 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 b hal£ I Aave 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-!.buil ' g o tion. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: PPLEMENT ORMATION REQUIRED OFFIIJSE ONLY `` �� ❑ OVER THE-COUNTER, � Jsm{ 1 �tS EXPRESS bu U ❑ STANDARD XAR.E , a MAJC)R PVApp_2011.doc revised 03116111