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15040030 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10050 IMPERIAL AVE CONTRACTOR:PETERSEN-DEAN INC PERMIT NO: 15040030 OWNER'S NAME: NEWARK,CA 94560 PHONE NO:(510)494-9982 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL } �/ INSTALL 26 ROOF MOUNTED PV MODULES(7.4KW) License Class L Lic.# Contractor �� r� /r`! �M�Date 14 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: 1 have and will maintain a certificate of consent to self-insure for Worker's mpensation,as provided for by Section 3700 of the Labor Code,for the ance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$28350 v 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:35717069.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that 1 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 PE DANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for i ection purposes. (We)agree to save 180 DAYS FRO INSPEC ION. indemnify and keep harmless the City f pertino against liabilities,judgments, costs,and expenses which may City a Inst said City in nsequence of the granting of this permit. Additiona applicant u ders ds and will comply ate: with all non-point source re ns rt up, o nicipal Code,Section 9.18. RE-ROOFS: Signature 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: 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). l 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 1 have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should 1 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 I ity Management District I performance of the work for which this permit is issued. will maintain compliance with the Cuperttn7S icipal C e, apter 9.12 and 1 have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Section&1550 permit is issued. I certify that in the performance of the work for which this permit is issued,1 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,1 6NSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,1 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 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 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION W'rCRMJT DDRESS: 10050 IMPERIAL AVE DATE: 04/06/2015 REVIEWED BY: MELISSA PN: 357 17 069 BP#: Q °`VALUATION: $28,350 PE: Building Permit PLAN CHECK TYPE: Alteration I Repair PRIMARY SFD or Duplex PENTAMATION SOLAR-RES USE: PERMIT TYPE: A WORK INSTALL 26 ROOF MOUNTED PV MODULES 7.4k SCOPE t l7it C lh�ch PI'vi C 1,11/ i) !'c:rrrair i ec: l��lcc 1'crrrir l E� Ocher I ch. Inv, 0/her Plumb lrrep 7sF>. I'lech hlv). kec Phmd>, l"ec' I v". Pec NOTE. This estimate does not include fees due to other Departments(ie.Planning,Public Works, Fire,Sanitary Sewer District,School District,etc . Thesefees are based on the prelimina information available and are onl an estimate. Contact the De t or addn'l info. FEE ITEMS (Fee Resolulion I1-053 C : 7/1/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 1 # Alternative Energy System Suppl,PC Fee: E) Reg. © OT 0.0 T hrs $0.00 $236.00 IPHOTOVRES Photovoltaic System PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. Q OT O.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: A(iministrativc Fee- 0 Work Without Permit? © Yes C) No $0.00 Advanced Planning Fee: $0.00 Select a Non-Residential 0 Travel Ducumenfatiori Building or Structure i Strong, Motion Fee: IBSEISMICR $3.69 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $2.00 SUBTOTALS: $5.69 $236.00 TOTAL FEE: 1 $241.69 Revised: 02/14/2015