14120057 CITY OF CUPERTINO BUILDING PERMIT
BUILDING AIDDA .SS: 22275 CARTA BLANCA ST CONTRACTOR:PETERSEN-DEAN INC PERMIT NO: 14120057
OWNER'S NAME:
NEWARK,CA 94560 PHONE NO:(510)494-9982
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
YJC10/o INSTALL 27 PANEL PV SYSTEM ON SFDWL ROOFTOP,7.4
License Class C39 I C 4 b ILic.M y6 W7 KW
Contractor PC-WS" 5e-4►l Date 20
I hereby affirm that I am licensed under the provisions o 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:$35000
1 have and will maintain Worker's Compensation Insurance,as provided for by
ection 3700 of the Labor Code,for the performance of the work for which this APN Number:32613050.00 Occupancy Type:
-Pqrmit 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 P�A-YS LLED 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
granting of this permit. Additionally,the applicant understands and will comp) sued/b 4"1
with all non-point source re u ons per the Cupertino Municipal Code,S n
9.18.
RE-ROOFS:
Signature to 5 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
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(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). 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 2 1 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Owner or authorized agen' Date:
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,1 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 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
9.18.
Signature Date
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22275 CARTA BLANCA ST CONTRACTOR:PETERSEN-DEAN INC PERMIT NO: 14120057
OWNER'S NAME:
NEWARK,CA 94560 PHONE NO:(510)494-9982
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL ❑
�f INSTALL 27 PANEL PV SYSTEM O SFDWL ROOFTOP,
License Clak- ��O. Lic.# \� A KW
Contractor Date-A
I hereby affirm at licensed under the provisions of Chapter 9
(commencing witheti 00)of Division 3 of the Business&Professions
Code and that my lice 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
I performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$35000
PN 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:32613050.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES I.F WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 18 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 F L T CALLED INSPECTI N.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:
with all non- t source regulations per the Cupertino Municipal Code,Section
l RE-ROOFS:
Signature Date t 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.
ElOWNER-BUIL � 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(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). 1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
1 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 1 store or handle hazardous
1 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 hot e Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain complia a with fhgCupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety C
Date
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
Compensation laws of California. If,after making this certificate of exemption,1 CONS U TIQN LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction'Iending 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 1 have read this application and state that the above information is
correct.1 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
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 22275 carta blanca st DATE: 12/11/2014 REVIEWED BY: Mendez
APN: BP#: j 'VALUATION: 1$35,000
=PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PPENTAMATION SOLAR-RE
USE: ERMIT TYPE:
WORK install 27 panel pv system on sfdwl rooftop, a e
SCOPE
Elec. Plan Check 10.0 1 hrs $0.00
Elec.Permit Fee: IEPERMIT
r)Yrrcv l'lum! �fr ;, Other Elec.Insp. 0.0 hrs $48.00
NOTE: This estimale does not include fees due to other Departments(i.e. Planning, Public Works,Fire,Sanitary Sewer District,School
District, etc. . Thesefees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 E : 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Alternative Energy System
Suppl. PC Fee: Q Reg. C) OT0.0 hrs $0.00 $236.00 IPHOTO VRES Photovoltaic System
PME Plan Check: $0.00 amps El a
Permit Fee: $0.00 $4$ 18FGEC200 Services
Supp/. Insp. Fee:Q Reg. Q OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $48.00
(,emwrtiction Tax.
Administrative Fee: IADMIN $45.00 0
Work Without Permit? 0 Yes Q No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential
Travel Documentation Fee: 1TRA VDOC $48.00 Building or Structure
i
Strong Motion Fee: IBSEISMICR $4.55 Select an Administrative Item
Bldg Stds Commission Fee_ IBCBSC $2.00
SUBTOTALS: $147.55 $284.00 TOTAL FEE: $431.55
Revised: 10/01/2014