15010123 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21075 MANITA CT CONTRACTOR:SANTA CRUZ WESTSIDE PERMIT NO: 15010123
ELECTRIC
OWNER'S NAME: RASTOGI LAXMI K AND RASHMI 2119 DELAWARE AVE DATE ISSUED:01/22/2015
OWNER'S PHONE: 4084462319 SANTA CRUZ,CA 95060 PHONE NO:(831)469-8888
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
�+ q INSTALL 19 PANEL PV SYSTEM ON SFDWL ROOFTOP 4.75
License Class /6 Lic.# — (O 2 — ! KW,PANEL UPGRADE 200 AMP
Contractor �&47— Date Z.
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1 hereby affirm that I am licensed under the provisio s 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
erformance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$17000
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:36223043.00 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. 1 agree to comply with all city and county ordinances and state laws relating WITHIN 180 DI'�.f3F 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 M LAS�1 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
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: G
with all non-point source regulations per the upertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature Date f z2 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 1 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. 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 1 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 ode,Chapter 9.12 and
I have and will maintain Workers Compensation Insurance,as provided for by the Health&Safety Code,Sections 2550 25533 nd 534.
Section 3700 of the Labor Code,for the performance of the work for which this )7
permit is issued. Owner or authorized agent: 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
ALTERNATIVE ENERGY PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 AE\
(408)777-3228•FAX(408)777-3333•build Inp(O7cuoertinon Ora
CUPERTINO
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OWNER NAME I P1 , lJ� E-1dAII, lJ
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CONTACT NAME{l PHO': C-MAIL.},,�
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❑OWNER ❑ OWNER-RUILDFR ❑OWNER AGENT CONfRACtOR ❑CONTRACTOR AGENT ❑ AR('HITECI" ❑ENGINEER ❑ DEVELOPER ❑ TENANT
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ARCHIITCI".RENGINEER NAME. LICENSE NUMBER BUSS IL
COMPAN}"NAME E-MAIL FAX
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STREG r ADDRESS ,/" �, t`r CITY,STAIL-ZIP - PHONE
USE OF - SFD or Duplex ❑ Multi-Family PROJECT IN X ILOL.AND PROJECT IN
STRUCTURE Le Cial URBAN IN'l'F.RFACF.AREA ❑ Yes No FLOOD ZONE ❑ Yes No
SOLAR PANEL ❑ ELEC-I RIC VEJ 1K'is('IIAROmG STATION ❑ SOLAR WAIER HLATING ❑ OTHER:
I ONSOLINPAA'E y': NUMBLR OF PANELS/UNITS KILOW'ATFS(COMMERCIAL ONLY) "TOTAL VALUATION$ III WILD
DESCRIPTION OF WORK
M 4
ERE{'EIVEU BY
By mV signature below,I certify to eac ,- e fol owing: I the property owner or authorized agent to act on the properl); Vner's behalf. ave read this
plication and the information I hay,&ovi is correct 1_a e read the Description of work and verify'it is accurrie. I agret tznaTfip y with all applicable local
ordinances and state laws relating fa{lildit g �trucl orize representatives of Cupertino to enter the above-ldent C pro erl far inspection purposes.
Signature of ApplicanVAgent. _ Date: _
h9ENTAI-INFORMATION REQUIRED OFFICBUSE ONLV
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Pl,'Apq�_20n.doc revised 03.16,7
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 21075 manita ct DATE: 01/22/2015 REVIEWED BY: Mendez
APN: BP#: / :� "VALUATION: 1$17,000
PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION
USE: PERMIT TYPE: SOLAR-RES
WORK install 19 panel pv system on sfdwl rooftop, panel upgrade 200 am
SCOPE
Elec.Plan Check 0.0 hrs $0.00
Elec.Permit Fee: IEPERMIT
Other Elec. Insp. 0.0 hrs $48.00
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works, Fire,Sanitary Sewer District,School
District,etc). These.fees 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 Ef' 7'1"13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 T-] # Alternative Energy System
Suppl. PC Fee: ) Reg. 0 OT 0.0 hrs $0.00 $236.00 1PHOTOVRES Photovoltaic System
PME Plan Check: $0.00 L2Eamps Electrical
Permit Fee: $0.00 $48.00 IBELEC200 Services
Suppl. Insp. Fee:) Reg. ) OT 0.0 1 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $48.00
Administrative Fee: 1ADMIN $45.00 )
Work Without Permit? ® Yes ) No $0.00 )
Advanced Planning Fee: $0.00 Select a Non-Residential )
Travel Documentation Fee: ITPA VDOC $48.00 Building or Structure
i
Strong Motion Fee: IBSEISMICR $2.21 Select an Administrative Item
Bldg 5tds Commission Fee: 1BCBSC $1.00
SUBTOTALS: $144.21 $284.00 TOTAL FEE: 1 $428.21
Revised: 01/06/2015