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15120106-DPCITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22273 CUPERTINO RD CONTRACTOR: CINNAMON SOLAR INC PERMIT NO: 15120106 OWNER'S NAME: JACKSON HARLAN V AND BARBARA P 1550 DELL AVE STE K DATE ISSUED: 12/11/2015 OWNER'S PHONE: 4085046406 CAMPBELL, CA 95008 PHONE NO: (408) 883 -7000 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ INSTALL (30) ROOFTOP MOUNTED SOLAR PANELS (8.4 License Class (2 — q � Lic. # KW) Contractor Date 1/2_111 1 (5�� 1 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: 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 Sq. Ft Floor Area: Valuation: $26748 performance of the work for which this permit is issued. 1 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; 32616075.00 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 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the bK granting of this permit. Additionally, the applicant understands and will comply Issued by: Date: with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. RE- ROOFS: Signature ate v All roofs shall be inspected prior to any roofing material being installed. If a roof is 1 { installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ OWNER - BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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 sale (Sec.7044, Business & Professions Code) 1, 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 1 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(x) should I store or handle hazardous I have and will maintain a Certificate of Consent to self- insure for Worker's material. Additionally, should l 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, Sect' as.25505, 2553 and 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent. permit is issued. 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 APPLICANT CERTIFICATION Lender's Address 1 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 • buildingPcupertino.org PROJECT ADDRESS n • / APN # / OWNER NAME T- PHONE E -MAIL O STREET ADDRESS FAX S/� C NTAC NAME PHO E-MAIZ n STREET AD RESS, f CIT , STATE, ZIP FAX ❑ OWNER ❑ OWNER- BUILDER ❑ OWNER AGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONT CTOR NAME LICENSE NUMBE LICENS�TYPE BUS. LIC # COMP Y NAME -MAIL FAX N�� �C..i�t 1GtJnavt 5 STREET ADDRESS CITY, STAT ZIP P ONE O ARCHITECT/ENGINEER NAM LICENSE NUMBER BUS. LIC # COMPANY NAME E -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF C� SFD or Duplex ❑ Multi - Family PROJECT IN WILDLAND PROJECT IN STRUCTURE: El Commercial LRBAN INTERFACE AREA El Yes YeS CI FLOOD ZONE ❑ Yes (�No a1/SOLAR PANELS ❑ ELECTRIC VEHICLE CHARGING STATION ❑ SOLAR WATER HEATING ❑ OTHER: FOR SOLAR PANELS: NUMBER OF PANELSk MTS: KILOWATTS (CO ERCLAL ONL }: TOTAL VALUATI � DESCRIPTION W 1 DB 17 r By my signature below, I certify to each of the following: I am the property owner or authorized agent to act s e al£ 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 '!ding construction. authorize representatives of Cupertino to enter the above - identified pro erty for inspection purposes. Signature of Applicant/Agent: 43nfrsn% Date: Z SUPPUMENTAL INFORMATION REQUIRED' i�I max' M zg r K f k ft i° ffi rR Py.+ 42 PVApp_2011. doc revised 03116111 r Le on Y rr!�L C-c CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION 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 preliminary information available and are only an estimate. Contact the Dept for addn7 info. FEE ITEMS (I'ec Resolution 11 -033 Ftf 7/1113,) 22273 Cupertino Rd DATE: 12/11/2015 REVIEWED BY: Phuong ligADDRESS: APN: 32616075 BP #: VALUATION: 1$26,748 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: O,0 PENTAMATION SOLAR -RE PERMIT TYPE: WORK I rooftop mounted solar pariels 8.4 K SCOPE 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 preliminary information available and are only an estimate. Contact the Dept for addn7 info. FEE ITEMS (I'ec Resolution 11 -033 Ftf 7/1113,) FEE QTY /FEE MISC ITEMS Plan Check Fee: $0.00 1 # $236.00 Alternative Energy System IPx07'OVPES Photovoltaic System Suppl. PC Fee: (F) Reg. 0 OT O,0 hrs $0.00 PME Plan Check: $0.00 Pen-nit Fee: $0.00 Suppl. Insp. Fee:(@ Reg. Q OT 0.0 lis $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Work Without Permit? 0 Yes) No $0.00 Advanced Planning Fee: $0.00 Select a Non - Residential Building or Structure 0� 726c: ZX}Llii'te;17CiT )Y t'Cc5: StronM Motion Fee: IBSEISMICR $3.48 Select an Administrative Item Bldt Stds Commission Fee: IBCBSC $2.00 °SUBTOTALS: $5.48 $236.00 _: TOTAL FEE: $241.48 Revised: 1010112015 E N J W LU co r� om W U o w o W uwi Z N J ivm >�Jm 3 m0 'o 9L0MZ£ #NdV o N EL aq wwoq ;D m 13 O o CL 0o` N tID VLOM bO `ONli83dno a � ao °� � O Z'P�N E0 L_ O U °pia s D. 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