B-2018-0020 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: CONTRACTOR: PERMIT NO:B-2018-0020
841 ROSE BLOSSOM DR CUPERTINO,CA 95014-4263(359 03 044) TESLAENERGY
OPERATIONS,INC.
SAN MATEO,CA 94402
OWNER'S NAME:BRESHEARS GREGORY GLEN AND WU-BRESHEARS CHE DATE ISSUED:02/22/2018
OWNER'S PHONE:408-613-3085 PHONE NO:(650)963-5100
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-10 Lic.#888104
Contractor TESLA ENERGY OPERATIONS,INC.Dale 12/31/2018 X BLDG X ELECT_PLUMB
1 hereby affirm that I am licensed under the provisions of Chapter 9(commencing —MECH X RESIDENTIAL—COMMERCIAL
with Section 7000)DIDivision 3 of the Business&Professions Code and that my
license is in full farce and effect. JOB DESCRIPTION:
(N)16 PANEL ROOF MOUNTED PV SYSTEM(4.8KW);(1)ENERGY
I hereby affirm under penalty of perjury one of the following two declarations: STORAGE SYSTEM(13.5);(N)200 AMP LOAD CENTER
1. I have and will maintain a certificate of consent to self-insure for Worker's REV#I ELIMINATE BATTERY BACK UP UNIT-ISSUED 3/29/2018
Compensation,as provided for by Section 3700 of the Labor Cade,for the
performance of the work for which this permit is issued.
r-tv1R` I have and will maintain Worker's Compensation lusurance,as provided for by
Section 3700 of the Labor Code,for the pefortnerme of the work for which this
permit is issued Sq,Ft Floor Area: Valuation:$14304.00
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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 35903 044
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 WORK 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 regulations per the C pertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 0 312 9/2 01 8 Issued by:Abby A e
411 Date:02/22/2018
OWNER-B IL ER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for ane of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed If a roof is
1. 1,as owner of the property,or my employees with wages as their sale installed without first obtaining an inspection,I agree to remove 01 new materials fur
compensation,will do the work,and the st—mre is not intended or offered far vupection.
sale(Ser.7044,Business&Professions Code)
z I,sa owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:03/29/2018
1 hereby aftbru under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS'1'O BE CLASS"A"OR BETTER
1. 1 have and will maintain a Certificate of Consent to self-insure for Worker's
Compeasotion,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z I have and will maintain Worker's Compensation lusurance,as provided for by I have 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 California Health&Safety Code,Sections 25505,25533,and 25534.I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
s. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should 1 store or handle hazardous
material.Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the sir 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 Code,Sections 25505 Z5533,and 25534.
Labor Code,l must forthwith comply with such in or this permit shall
be deemed revoked. Owner or authorized agent:
AI'PLICAN'I'CERTIFICATION Date:03/29/2018
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING 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 ARCHITECT'S DECLARATION
Cod.,Section 9.18. I understand my plans shall be used as public records.
Signature Date 03/29!2018 Licensed
Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228• building@cupertino.org PEMIT#B-Z,E> Od2
CUPERTIN0 REV#_j__ DEP#
❑NEW CONSTRUCTION ❑ADnDITION ❑ALTERATION❑T.I. ❑MEP ❑RE-ROOF ❑SWIMMING POOL/SPA
PROJECT ADDRESS V , APNI
OWNER NAME PHONE,/ ? E-MAIL
STRERT ADDRESS CITY,STATE,ZIP
CONTRACTOR NAME []OWNER-BUILDER COMPANYNAME LICENSE NUMBER LICENSE TYPE
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STREET ADDRESS ^� TY,STATE,ZIP
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E-MAIL m�r I I HONE H S.LIC p
❑ARCHITECT []OWNER[]OWNER AGENT 'CONTRACTOR AGENT[]ENGINEER[]DEVELOPER[]TENANT
CONTACT NAME V 1�IPrC E-MAIL A
STREET ADDRESS d r� CITY,STATE,ZIPPHO r. /�
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DFaCRIPTON !�
SINGLE-FAMILY/DUPLEX ❑MULTI-FAMILY []INDUSTRIAL []COMMERCIAL
EXISTING USE EXISTING SF NEWPLOORSF PORCHSF DECKSF DEMOSF STORIESp TOTALNETSF USE TYPE OCC SQ.FT. VALUATION($)
REMODEL REMODEL KITCHEN REMODELOTHR GARAGE []pITACHED
BATHROOM SF SF SP SP []DETACHED
EXISING ❑YES rLIC11LER []YES SECOND STORYADDITION ONO
FIRE SPRINKLERS[]NO ❑NO
DWELLING SECONDDWELLMG []yM[]ATTACHED[]DETACHED OTHER
UNITS I UNIT ADDITON: []NO 5 F
POOLS[ []FIBERGLASS []VINYL-LINED[]GUNITE []PREFABRICATED
POOL-SF SPA-sF I SPAATTACHED DYES U NO TOTAL-5F
RECEIVED BY: TOTAL VALUATION:
Corruuurcinla�Multi-Frzn EP BrdldbrQs vifh Public Swiru rrPonls�egu'es Dann4 rerfolE e�' rer W!tont!a/y�om7 —
RE-ROOF EXISTING ROOF TYPE: F]BUILT-UP ROOF❑ASPHALT SHINGLES F]WOOD SHAKES F]WOOD SHINGLES E]TILE OTHER(SPECIFY)
REMOVE/REPLACE❑NOIF NO PLYWOOD ❑h" [-]3/8" PLYWOOD TYPE: PITCH: ROOF CLASS
❑YES
9O LAYERS THICKNESS❑5/8" OTHER ❑OSB ❑CDX OTHER •12 A
PROPOSED ROOF TYPE:[]BUILT-UP ROOF[]ASPHALT SHINGLES[]WOOD SHAKES❑WOOD SHINGLES[]OTHER
*Provide a signed copy of the Cupertino's Tear-Off Policy SF pof SQUARES
By my signature below I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf.I
have read this application and the information I have provided is correct.I have read the Description of Work and verify it is accurate.I agree
to comply with all applicable local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to
enter the above-identified property for inspection purposes. I acknowledge and authorize all information contained on this application form
to be made available for public record.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED
*New SFD/Second Dwelling Units/Multifamily Dwellings:A Demolition permit is required prior to issuance of a building permit for all new construction.
*Commercial Buildings:Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project.
*Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application.
*HOA-Provide a letter of approval from the Home Owner's Association
B1dgApp2017.dac revised 08/01117