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14080039 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21430 VAI AVE CONTRACTOR:CALIFORNIA SOLAR PERMIT NO: 14080039 SYSTEMS OWNER'S NAME: GOVWD SUTLUR 1511 E ORANGETHORPE AVE STE D DATE ISSUED:08/06/2014 OWNER'S PHONE: 4082521827 FULLERTON.CA 92831 PHONE NO:(800)324-1978 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL INSTALL 22 FLUSH,ROOF MOUNTED PV PANELS License Class 'C'09 Lie.# �� (5.61 KW) Contractor C��F.a. �o� Date �' IP L l K hereby affirm that I am licensed V11 t e 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 Compensation,as provided for by Section 3700 of the Labor Code,for the rformance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$20000 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:36205025.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that l have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. l agree to comply with all city and county ordinances and state laws relating WITHIN O MIT 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 ALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence ofth granting of this permit. Additionally,the applicant understands and will co e D e: G� O with all non-point source regulations per the Cupertino Municipal Co ion 9.18. RE-ROOFS: Signature ai� ��" All roofs shall be inspected prior to any roofing material being installed. if a roof is installed without first obtaining an inspection,l 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 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(Scc.7044, Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sce.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 aCertificate 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 1 have and will maintain Workers Compensation Insurance,as provided for by the Health&Safety Code,Sections 25>5,25533,and 25534. Section 3700 ofthe Labor Code,for the performance of the work for which this �1 �%�� Owner or authorized agent: permit is issued. I certify that in the performance of the work for which this permit is issued,l 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,l must l 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 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 9.1& Date ALTERNATIVE ENERGY PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION ig 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228•FAX(408)777-3333•building(dcupertino.org \ \ PROJE A\ # n O? O ERNAM E-MAIL V / O STREET ADDRESS � CITY,STATE,ZIP FAX CONTACT NAME ICE s` C C e E-MAIL ST DRE Y,ST TE,ZIP '1'1 ` FAX � � C C\,�.-�s s �. ❑ OWNER ❑ OWNER-BUILDER ❑ OWNERAGENTONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CTRACTO ME ICENSE NL�Of$ LICFS TYPE BUS.LIC# Q }" COMPANY E-MAIL FAX ST DDRESSCI AT ,ZIP PAq trt-% COIN- 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 IN 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 PANELSAJNITS: KILOWATTS(COMMERCIAL O�NL1Y): C / ' TOTAL VALUATION: DESCRIPTION F OR 2 ,p Cid 10 By my signature below,I certify to each of the following: I am the property owner or authorized a o act on prope ebalf. I have read this application and the information I have provide s correct. I have read the Description of Work and verify accurate. I agree to comply with all applicable local ordinances and state laws relating to ilding nstrtction. I authorize representatives of Cupertino ter the above-i entife property for inspection purposes. Signature of Applicant/Agent: Date: �r 1 SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY w ❑ OVER-THE-COUNTER a F ❑ EXPRESS U U , C� STANDARD U z ❑ 'LARGE F ❑ MAJOR PVApp_2011.doc revised 03/16/11 CITY OF CUPERTINO FEE ESTIMATOR— BUILDING DIVISION ADDRESS: 21430 VAI AVE DATE: 08/06/2014 REVIEWED BY: MELISSA APN: 362 05 025 BP#: IIAO5003 VALUATION: 1$20,000 10 *PERMIT TYPE: Building Permit PLAN CHECK TYPE. Alteration / Repair PRIMARY SFD or Duplex PENTAMATION USE: PERMIT TYPE: SOLAR-RES WORK INSTALL 22 FLUSH ROOF MOUNTED PV PANELS 5.61k SCOPE Li NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . These ees are based on the preliminar information available and are only an estimate Contact the De t or addn 7 info, FEE ITEMS (Fee Resolution 11-051) Elf 7''1/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 = # Alternative Energy System Suppl. PC Fee: Q Reg. 0 OT 1 0.0 1 hrs $0.00 $236.00 ipHoTovREs Photovoltaic System PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:(j) Reg. 0 OT0 0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 0 Work Without Permit? 0 Yes (j) No $0.000 Advanced Planning Fee. $0.00 Select a Non-Residential Q Building or Structure 0 Strong Motion Fee: IBSEISMICR $2.60 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $3.60 $236.00 TOTAL FEE: 1 $239.60 Revised: 07/10/2014