13120087I
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20977 FAIRWOODS CT
CONTRACTOR: CLEAN SOLAR
PERMIT NO: 13120087
OWNER'S NAME: KEVIN VERGI-10
1445 KOLL CIR STE 109
DATE ISSUED: 12(1012013
OWNER'S PHONE: 4088293050
SAN JOSE, CA 95112
PHONE NO: (408) 217-8876
I CENSED CONTRACTOR'S DECLARATION.
JOB DESCRIPTION: RESIDENTIAL ® COMMERCIAL
License Class to `7 `f- Lac• # `r
INSTALL 26 ROOF TOP, FLUSH MOUNTED PV PANELS (6.5 KW)
Contractor, ms 3 :Date % 2,-'t 0 -.1
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.
I hereby affirm under penalty of perjury one of the following two declarations:
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.
Sq. Ft Floor Area:
Valuation: $30255
have and will maintain Worker's Compensation Insurance, as provided for by
APN Number: 35913 115.00
Occupancy Type:
Section 3700 of the Labor Code, for the performance of the work for which this
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 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
Date r5 /71
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
9.18. ,�,.
Si nature t ``.c-•--- i`Date f-3
g _'�'
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
0 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
1, 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 (See.7044,
Business & Professions Cade)
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
I 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 I 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, Seetkons,2595,25543, and 25534.
�
//3
Section 3700 of the Labor Code, for the performance of the work for which this
i —� Date: /
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
CONSTRUCTION LENDING AGENCY
Compensation laws of California. If, alter making this certificate of exemption, I
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
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 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
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
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
COMMUNITY DEVELOPMENT DEPARTMENT ° BUILDING DIVISION
1O3OOTORREAVENUE ^CUPERT\NO.CA 95014-3255
(408) 7T7-3228^ FAX(4O8)777-3333 - building2cupertino.oEg
PROJECT ADDRESS
-7 7 /-a Zk�je-DL
6--r
APN 4 13 5; 1�
1 5
OVVNER NAME A
Ke v
PHONE
E-MAIL
CITY, STATt,.1P FAX
CONTACT NAME
PHONE
E-MAIL
STREET ADDRESS
CITY, STATE, Zi P
I FAX
AOWNER F1 OWNER -BUILDER OW14ER AGEN r
kONTRACTOR 0 CONTRACTOR AGENT ARCHITECT ENGINEER 11 DEVELOPER 171 TENANT
CONTRACTOR NAME
la Y
LICENSE NUMBER
BU& LIC 9
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
it
PHONE
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC
COMPANY NAME
-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF SFD or Duplex 0 Multi -Family
STRUCTUp,Ej 0 Commercial
PROJECT IN WILDLAND
URBAN INTERFACE AREA M Yes I- No
L11*
PROJECT IN
FLOOD ZONE C3 Yes ro
_T_
I�SOLAR PANELS
0 ELECTRIC VEHICLE CHARGING STATION 11 SOLAR WATER HEATING I
i -
OTI-IER.
FORS01-4R PAIVEI-9: NUMBER OF PANELS/UNITS:
f4 KILOWATTS
azl
TISN.
DESCRIPTION OF WORK
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 ofWork and verify it is accurate, I agree to com1ply with all applicable local
ordinances and state laws relating Urbq)*Iding construl4on. I author,ze/,7presentati ves of Cupertino to enter the above- identified property for inspectic n purposes.
Signature ofApplicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED
OFFICE USE ONLY
te
EXPRESS
STANDARD
LARGE
PyAzp.201ldocrevised U&12&112
CITY OF CUPERTINO
VVV V Zr A T49? — VJ TIVI)TITC 1Ll
J'*ch, Plan Che(,�k
A-Mch, Permit 1,
Other,ldech. I Insp,
1,11c,ch. fwp. Few:
phunb. plarl ("'hed'
Plumb, hisp. Fee:
Elec. Plan Chcwk I I
I_T11"f'.. Permit 1"v
01her Flee. Insp.
cc
NOTE: This estimate does not include fees due to other vepartments {i.e rianning, ruptic w orKs, rare, auruxuryarwvr "facr SE'l, Owl vug
District etc These eecare based on the nrefilm"ina information available and are on1van estimate. Contact the DWILoraddn'l in o.
FEE ITEMS LTee -Resolution 11-053 Eff 7111131
FEE
DATE: 12/10/2013
REVIEWED BY: MELISSA
APN: 359 13 115
$0.00
F::E] #
$229.0011PHOTOVRES]
Alternative Energy System
Photovoltaic System
7-
!*PERMIT TYPE: Buildina Permit
"M 61
A
3 l
I PRIMARY
SFD or Duplex
I USE:,
$0.001
PENTAMATION
SOLAR -RLS
PERMIT TYPE: Al
$0.00
INSTALL 26 ROOF it FLUSK MOUNTED PV PANELS (605 W)
Permit Fee:
$0.00
'Suppl..Irisp. Feer Reg. .O OT
J'*ch, Plan Che(,�k
A-Mch, Permit 1,
Other,ldech. I Insp,
1,11c,ch. fwp. Few:
phunb. plarl ("'hed'
Plumb, hisp. Fee:
Elec. Plan Chcwk I I
I_T11"f'.. Permit 1"v
01her Flee. Insp.
cc
NOTE: This estimate does not include fees due to other vepartments {i.e rianning, ruptic w orKs, rare, auruxuryarwvr "facr SE'l, Owl vug
District etc These eecare based on the nrefilm"ina information available and are on1van estimate. Contact the DWILoraddn'l in o.
FEE ITEMS LTee -Resolution 11-053 Eff 7111131
FEE
QTYIFEE
MISC ITEMS
Plan Check Fee:
$0.00
F::E] #
$229.0011PHOTOVRES]
Alternative Energy System
Photovoltaic System
Suppl. PC Fee: (E) Reg. 0 OT��s
$0.001
PME Plan Check:
$0.00
Permit Fee:
$0.00
'Suppl..Irisp. Feer Reg. .O OT
0-0-1
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Adininistrative J7ee:
0
Work Without Permit? 0 Yes (E) No
$0.00
Advanced Planning
$0.00
Select a Non -Residential,
Building or Structure
0
7 -ravel Doczwientation .Fees:
Strong Motion Fee: IBSEISAffCR
$3.03
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$2.00
$O
� TA
$5.031
$229.00
A
T_,!TL
D3VBT
Revised: 10/0112013
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