B-2018-1048 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1048
19851 LINDENBROOK LN CUPERTINO,CA 95014-4539(369 23 014) TESLA ENERGY
OPERATIONS,INC,
:JUSTIN JERIN AND LOVER KAVITA M S 6/21/2018
O 08-772-8204 PHONE NO:(650)963-5100
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B.C10,C46 Lic.#888104
Contractor TESLA ENERGY OPERATIONS,INC.Date 12!31/2018 X BLDG X ELECT—PLUMB
I hereby affirm that I am licensed under the provisions of Chnpter 9(commencing —MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
(N)15 PANEL ROOF MOUNTED PV SYSTEM-(4.875 KW;(N)
I hereby affirm under penalty of perjury one of the following two declarations: PANEL(125 AMP)
t. 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.
have and will maintain Worker's Compensation Insurance,as provided for by
U@U, Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$7215.00
APPIJCANT
'=Td
I certify that I have read this appllcafion 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 36923 014
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 co y with all non-point
source regulat'q(ts per the Cupedino Municipal Code,Section 9.18, 180 DAYS FROM LAST CALLED INSPECTION.
Signature IU` Date 06/21/2018 Issued by:Jasmine Archbold
Date:06/21/2018
OWNER-BUILDER DECLARATION
I hereby afilrut that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed,If a roof is
r. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,1 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)
z. I,as owner of the property,am exclusively contracting with liceused Signature of Applicane
contractors to construct the project(See.7044,Business&Professions Code). Date:06/21/1018
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
t. I have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Lubar Code,for the
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. 1 have and will maintain Worker's Compensation Insurance,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 25534.1 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(.)should 1 store or handle hazardous
shall not employ n in an so as to become subject to the material.Additionally,should 1 use equipment or devices which emit hn o rdous
p y any porous y manner J air watan inants as defined by file Bay Ar as Air Quality Management District 1
Worker's Compensation laws of California.If,after making this certificate of will mafnhtin camplionce with the pertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Ca a oetions 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked Owner or authorized agent:
APPLICANT CERTIFICATION Date:06!21/2018
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 willcomply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Coda,Section 9.18. 1 understand my plans shall be used as public records.
SignatureDate 06!21/2018 Licensed
Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2018-1048
19851 LINDENBROOK LN CUPERTINO, CA 95014-4539 (369 23 014)
TESLA ENERGY
OPERATIONS, INC.
FREMONT, CA 94555
OWNER'S NAME:
DATE ISSUED: 06/21/2018
OWNER'S PHONE:
PHONE NO: (
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class C10 Lic. #888104
Contractor TESLA ENERGY OPERATIONS, INC. Date 12/31/2018
X BLDG X ELECT —PLUMB
MECH X RESIDENTIAL COMMERCIAL
I hereby affirm that I am licensed under the 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.
JOB DESCRIPTION:
(N) 15 PANEL ROOF MOUNTED PV SYSTEM - (4.875 KW; (N) PANEL
I hereby affirm under penalty of perjury one of the following two declarations:
(125 AMP)
t. I have and will maintain a certificate of consent to self -insure for Worker's
REVISION #1 - RELOCATE PANELS TO REAR OF RESIDENCE -
Compensation, as provided for by Section 3700 of the Labor Code, for the
ISSUED 8/27/2018
performance of the work for which this permit is issued.
2.e2. I 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
Sq. Ft Floor Area:
Valuation: $7215.00
permit is issued.
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
36923 014
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 Cupe 'no Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
)� /
Signature Date 8-27-2018
Issued by: Jasmine Archbold
Date: 06/21/2018
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RE -ROOFS:
following two reasons:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
1. I, 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. I, as owner of the property, am exclusively contracting with licensed
Signature of Applicant:
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 8-27-2018
1 hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
r. 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 for which this permit is issued.
HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance, 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. 1 will
permit is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
3. I certify that in the performance of the work for which this permit is issued, I
Health & Safety Code, Section 25532(x) should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the
material. Additionally, should I use equipment or 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 Code, Sections �
Labor Code, I must forthwith comply with such provisions or this permit shall
-
be deemed revoked.
Owner or authorized agent:
APPLICANT CERTIFICATION
Date: 8-27-2018
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
Code, Section 9.18.
1 understand my plans shall be used as public records.
Licensed
Signature Date 8-27-2018
Professional