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14110093 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21881 HERMOSA AVE CON'1'RACTOf., PERMIT NO: 141 10093 OWNER'S NAME: PEGGY&IRVIN JOHNSTON DATE ISSUED: 11/17/2014 OWNER'S PHONE: 4088630589 PHONE NO: IT LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL E] INSTALL 14 ROOF TOP, FLUSH MOUNTED PV PANELS, License Class 1_J / Lie.# ( 3.78KW Contractor(/ VG T of V Date l 1-0— � 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. 1 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:$14000 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:35716073.00 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 I80 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 '�j""� granting of this permit. Additionally,the applicant understands and will comply ss Date: with all non-point source regulations per the Cupertino Municipal Code,Section �.. 9.18. RE-ROOFS: SignatureDate t/� All roofs shall be inspected prior to any roofing material being installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION Signature of Applicant: Date: [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) I,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. 1 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(a)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,Sections 25505,25 3,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this l �� 7—/ I permit is issued. Owner or authorized agent: Dad. 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 I certify that l 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 ALTERNATIVE ENERGY PERMIT APPLICATIO q COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION OAE 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 l (408)777-3228• FAX(408)777-3333• building a(bcupertino.orq CUPERTINO 1 PROJECT ADDRESS APN#� MQ. �O _ O1 OWNER NAM �— PHONE E-MAIL - 'Vf _L V t' -�6 S-6S8 STREET ADDRES�2 .� C� �TATEZ--235 'SI�L�( s G r y FAX o'0 � V i CONTACT NAME C WtONE"7E-MAIL w �� evt eviU a,�ca�, STREET ADDRESS CITY,ST TE, ZIP FAX F C7'1 S-T, *l75 �—Ius 92 780 ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT Pr- 'TRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRAC,IQR NAME LICENO�r�Ji%, LIC NSE TYPE BUS LIC# COMPANY NA S E-MAIL FAX l l til F C` d-1 T/ti'k ST l�e ADDRESS E, �� 'C#l 7� CITY, s-+',1 9'17 SI& 7 l Y-640--13 Y b ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑ SFD or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT rN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes ❑ NO FLOOD ZONE ❑ Yes ❑ NO ❑SOLAR PANELS ❑ ELECTRIC VEHICLE CHARGING STATION ❑ SOLAR WATER HEATING ❑ OTHER: FOR SOLAR PANELS: NUMBER OF PAN S/UNITS: KILOWATTS(CE+AL ONLY" TOjeL VALN: 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 prope mvner' ehalf. I have read this application and the information I have provided is correct. have read the Description of Work and verify it is accurate. I agree comply with all applicable local ordinances and state laws relating to bu "ng constructio I a thorize sentatives of Cupertino to enter the above-identified prop e [for inspection purposes. Signature of Applicant/Agent: Date: �/��71 SU MENTAL INFORMATION REQUIREDOFFICELTSE"oi,LY " CD OV$R-THE COUNTER a. EXPRESS U M ,❑ STANDARD U C LARGE 0 MAJOR PVApp_2011.doc revised 03/16/11 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION W�PERMIT DDRESS: 21881 HERMOSA AVE DATE: 11/17/2014 REVIEWED BY: MELISSA PN: 357 16 073 BP#: �j� 9?) `VALUATION: $14,000 PE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex PENTAMATION SOLAR-RE USE: PERMIT TYPE: A WORK INSTALL 14 ROOF TOP FLUSH MOUNTED PV PANELS 3.78kW SCOPE F-1 Ll NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,ete.). Theseees are based on the preliminar information available and are only an estimate. Contact the De t or addn'l in o. FEE ITEMS (Fee Resolution 11-053 Eff -%1113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 = # Alternative Energy System Suppl. PC Fee: (F) Reg. ® OT 0.0 hrs $0.00 $236.00 1PHOTOVRES Photovoltaic System PME Plan Check: $0.00 Permit Fee: $0.00 Supp1. Insp. Fee:Q Reg. Q OT0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 0 Work Without Permit? 0 Yes ) No $0.00 G Advanced Planning Fee: $0.00 Select a Non-Residential Building or Structure Strong Motion Fee: IBSFISMICR $1.82 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $2.82 $236.00 TOTAL FEE: $238.82 Revised: 10/01/2014