13090105 BUILDING ADDRESS: 21044 HAZELBROOK DR CONTRACTOR:PETERSEN-DEAN INC PERMIT NO:13090105
OWNER'S NAME: REGNER CUNANAN 7980 ENTERPRISE DR DATE ISSUED:09/16/2013
OWNER'S PHONE: 4082538714 NEWARK,CA 94560 PHONE NO:(510)194-9982
R LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El CO]�MERCIALE]
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License Class( Lii(c..## q INSTALL ROOFMO�AVT EIlD PV SYSTEM 171PAN PANELS,4.25
Contractor 11JG Date d KW
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.
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:$18000
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 APN Number:32655034.01 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
EIlD
correct.I agree to comply with all city and county ordinances and state laws relating ���,�� ll�®����®�PERMIT ISSUANCE®�
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 FROM LAST 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: I to
with all n - 'nt source regulations per the Cupertino Municipal Code,Section �ho
9.18.
9A/ I RE-ROOFS:
Signature Date ® Y 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 DECLARA'T'ION
T hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
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. T 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 I 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 by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance 'th th Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Cod Se i s 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this om
permit is issued. Owner or authorized agent: Dat
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,I 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 ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
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
ECI'I'Y OF eCUP EI TffNO
FEE IESTEMA1I'OR—BUILDING DIVISION
ADDRESS: 21044 heselbrook dr DATE: 09/16/2013 REVIEWED BY: Mendez
AP BP#: *VALUATION: $18,000
;PERMITTYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Duplex PENTAMATION SOLAR-RES
USE: PERMIT TYPE:
WORK install roof mounted pv system 17 panels, 4.25 kw
SCOPE
Leech. Ylan Check Plumb, Plan Check Elec..,Plan Check
EX--f"11,
. Permit Fee: Plumb. Permit Fee: F,lec•. Permit Fee:
Other A9erh.Insp. Other Plumb Insp. OtherElec.Insp.
11ech.Insp,Fee: Phenh. hisp.Fee: Elec,Insp..Fee:
NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc . TheseLees are based on the prelhWdna information available and are onl an estimate. Contact the Dept-for addn'l in o.
FEE STEMS (Fee Resolution 11-053 Elf. 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Alternative Energy System
Suppl.PC Fee: E) Reg. 0 OT 0.0 hrs $0.00 $229.00 IPHOTOVRES Photovoltaic System
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Feer Reg. 0 OT Q,Q hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Construction Tax:
Adminimrative Fee: 0
Work Without Permit? 0 Yes E) No $0.00 E)
Advanced Planning Fee: $0.00 Select a Non-Residential E)
Trcn-el Documentation Fees: Building or Structure
Strong Motion Fee: IBSEISMICR $1.80 Select an Administrative Item
ajd g_Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $2.80 $229.00 TOTAL FEE: $231.80
Revised: 08/01/2013