B-2018-0661 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0661
19100 MEIGGS LN CUPERTINO,CA 95014-3562(375 35 048) TESLA ENERGY
OPERATIONS,INC,
SAN MATEO,CA 94402
OWNER'S NAME: DATE ISSUED:05/01/2018
OWNER'S PHONE: PHONE No:(650)963-5100
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B C10 C46 Lic.#888 04
Contractor TESLA ENERGY OPERATIONS INC Date 12/31/2018 $BLDG—ELECT—PLUMB
1 hereby affirm that 1 am licensed under the provisions of Chapter 9(commencing —MECH X RESIDENTIAL—COMMERCIAL
with Section 7000)of Division 3 a]the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
(N)20-PANEL ROOF MOUNTED PV SYSTEM(6.3 KW)
I hereby affirm under penalty of perjury one of the following two declarations:
r. 1 have and will maintain a certificate of consent to self-insure Por Workci's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
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
permit is issued. Sq.Ft Floor Arco: Valuation:$9324.00
APPLICANT CERTIFICATION
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 AYN Number: Occupancy Type:
and slate laws relating to building construction,and hereby authorize 375 35 048
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,costs,and expenses which PERMIT EXPIRES IF WORI{IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulat Ir per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 05/01/2018 Issued by:Jasmine Archbold
Date:05/01/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt team the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any rooting material being installed,If a roof is
1. 1,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
2. 1,as owner ofthc property,am exclusively contracting with lised Signature ot'Applicant:
contractors to construct the prcen
project(Sce.7044,Business&Professions Code). Date:05/01/2018
1 hereby affirm under penalty of perjury one of the following three declarations: ALL RDOG COVERINGS TO BE CLASS"A"Olt BETTER
1. 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
performance of the work fawhich this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. I have and will.maintain Worker's Compensation insurance,as provided for by I lava read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this Cultural.Health&Safety Code,Sections 25505,25533,and 25534.1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
a. I certify that in the performance of the work for which this permit is issued,l Health&Safety Code,Section 25532(+)should 1 store or handle hazardous
shall not employ any person in any manner so as to become subject to the material.Additionally,should 1 use equipment at-devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California.If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Cade 9 etions 25505,25533,and 25534.
Labor Code,l must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date;05/01/2018
1 certify that I have read this application and stale that the above information is CONSTROCTION LENDTNO AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit Is issued(Sec.3097,Civ C,)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City In Lender's Address
consequence of the granting of this permit.Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCIII'I'EC'1"S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
SignatureLicensed
Date 0 5/0 112 01 8
Professional