B-2016-3300 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3300
1145 STEEPLECHASE LN CUPERTINO,CA 95014-5816(359 31 051) CLEAN SOLAR INC
SAN JOSE,CA 95112I
OWNER'S NAME: YUSEM STUART I DATE ISSUED:12/20/2016
OWNER'S PHONE:408-857-5830 PHONE NO:(408)217-8876
T JCENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-10:C-46 Lic.#910849
Contractor CLEAN SOLAR INC Date 02/28/2018 X BLDG _ELECT _PLUMB
MECH X RESIDENTIAL_COMMERCIAL
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. JOB DESCRIPTION:
(N)12 PANEL ROOF MOUNTED PV SYSTEM(4.02 KW)
I hereby affirm under penalty of perjury one of the following two declarations:
J., 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
�/i.)-'' Section 3700 of the Labor Code,for the performance of the work for which this
J permit is issued. Sq.Ft Floor Area: Valuation:$23429.00
s.'P.__ . 6. Et. 0 s
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 359 31 051
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�l"llw� ��3 av Date 12/20/2016 Issued by:Abby Ayende •
Date: 12/20/2016 1
OWNER-BUILDER DECLARA ON /
I hereby affirm,that I am exempt from the Contractor's License Law for one of theRE-ROOFS;
following two reasons: All roofs shall be inspe ted 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:12/20/2016
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
i. 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 84 Safety Code,Sections 25505,25533,and 25534. I will
maintain compliance With the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued.
a I certify that in the performance of the work for which this permit is issued,I Health&Safety Core,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 I
Worker's Compensation laws of California. If,after making this certificate of will maintain complianlce 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 25505,2553 and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
AIM
j
be deemed revoked. C Owner or authorized agent: A�
APPLICANT CERTIFICATION Date:12/20/2016 8
certifyI that I have read this application.and state that the above information is s` �` w! s 01 k ''"
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 t e performance
relating to building construction,and hereby authorize representatives of this city of work's for which this;permit is issued(Sec.3097,Clv 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,
Lender's Address
judgments,costs,and expenses which may accrue against said City in 1
consequence of the granting of this permit. Additionally,the applicant understands ARCHITECT'S DECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal I understand my plans shall be used as public records.
Code,Section 9.18.
Licensed
Signature Date 12/20/2016 Professional
r
:
ALTERNATIVE ENERGY PERMIT APPLICATION
„. .
t=---.
.).!,
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
: ::,•:;.1 : ! g
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 '
(408)777-3228 . FAX(408)777-3333.buildina@.cutaertina.brq
CUPERTINO 9
PROJECT ADDRESS la5: (44CIAriksic.,, Ltriii, APNi,.' 551_ 9 _ 051
OWNERNAME 51J,ca- ,- t5.,avi PE )si 5
6-30 E-MAIL ,
UY-4/11e,‘.1 C(.. .0...0A/V
STREET ADDRESS I(1.45- ( iketitet...% Ln CITY,STATE,ZIPeom,,nvv.„-. _ ,GA I O14 F.AX
CONTACT NAME9 14)4_ . j
wite, oce-eJtD
' .240.105-0-2,,-'2,61--(q NiLeothanie_Ai etieat5Accr.c,)
- v
' STREET ADDRESS ittifi kivo Gir qt.. fol CITY,STATE,ZIP ,5. tiv Lkt).x.03 i sl(2, (A405)2,I 0 Is,715
0 OWNER 0 OWNER-BUILDER 0 OWNER AGENT 0 CONTRACTOR IS144c,)NTRACTOR AGENT 0 ARCHITECT D ENGINEER 0 DEVELOPER 0 TENANT
CONTRACTOR NAME.jek. la 1,-,1,.,L.,./porkvAA
LICENSE NUMBER Ci 10549 LICEN$.F.TYPEctap BUS.TIC#
(.1"C
COMPANY NAME
a atAn %iteUtrj 1 - E-MAIL Ir\CP-oedeatii5D CL(.1co14 F10x))21G -615-7 b
STREET ADDRESS 14145-KM cir-- ‘51-c, tog CITY,STATE,ZII2,,forvArje„,cfic q 5.1 i 2.... PHONE
ARCHITECT/ENGDIEER NAME LICENSE NUMBER . BUS.LIC 4
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF SFD or Duplex 0 Multi-Family PROJECT IN WILDLAND PROJECT IN
STRUCTURE: 0 Commercial URBAN INTERFACE AREA 0 Yes A-No FLOOD ZONE 0 Yes drNo
,
SOLAR PANELS 0 ELECTRIC VEHICLE CHARGING STATION 0 SOLAR WATER HEATING 0 OTHER:
FOR SOLAR PANELS: NUMBER OF PANELS/UNITS: Ira_ KILOWATTS(COMMERCIAL ONLY): I, iN TOTAL VALUATIONz3 t d'al 41
1 4
DESCRIPTION OF WORKi A,:ruicuri_01,„ eb -, ,,Nur
a36,,, a ::, outer ,96.euLts
.,_i_v.. .../ v
, ...
By my signature below,I certify to each of the following: lam the property owner or authorized agent to at on the property owner's behalf. I have read this
application and the information I have provided is conect. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relatin ldinig,construction. I authote representatives of Cupertino to enter the above-i entitled property for inspection purposes.
Signature of ApplicantdAoent: 7" 1,, 1,/ ,Z ,._._, A -0.!;. , 'Ail Date: / 1.---U 1 ((6)
SUPPLEMENTAL INFORIVIOIEQUIRED
AgegglitiMMEIWOW-44:
.P.;•,,,,,-i---7,- ; f.-_, -1,,,,t:r4,-,7,1-",- -.fW,t-rTik,-,1- -1,1kEZi.--,
k--7.,:t4.146-
' LI101 fr ,' VERgESE:CoMt;1,
TEW,17-S-2- 1.
7'it: lsw.Fkf..i.wmrmV*.T-.0-V,AWRI
?T‘'.4,,,ri0,..',gEgi5L-patsw-r14:Q4,-4A-14,,cfaAik,
MUllif.Ws-1-141-M.VW",*.MY-te-IRM-14
01,4g0;:i1PlibgINOWNIFig,AVESA,
7-1.....;-1, .„--17 -17:"
tiVe-A, 04w-1Mti-a,
-,,,,Effc,-,,,k,-,t116',,A%-rd•fwg..TA-seq_m-Nnvp, J
*--fik,,:t.v-s----.0.s,A-:-s-mvpu-•-2*i--_-§r.w:4„,g4,
tliftz.:CZ,S,IgSqlgMggFtntiattaVtt
f
PVApp_2011.cloc revised 03116111
1