B-2018-0780 ALTERNATIVE ENERGY PERMIT APPLICATION
y s
COMMUNITY DEVELOPMENT DEPARTMENT * BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
P'E TI
(408) 777. 3225 * FAX (408) 777-3333 ,o buiidln cupertino.or�
NO
PROJECT ADDRESS APN#
3
OWNER NAME PHONE E-MAIL
`moi ho L6 rot 7 _ ?oe6
STREET ADDRESS CITY, STATE, ZIP FAX
QJZJ��e E61;"V Qu PER_:7%-j C_4
CONTACT NAME PHONE E-MAIL wyu � 10K, C6 w
STREET ADDRESS CITY, STATE, ZIP FAX
F29159 (3 9�j .
13OWNER 11 OWNER-BUILDER 13OWNER AGENT 14 CONTR.ACTQR. 13 coNTRACToR AGENT 13 AR°CWTECT 11 ENGINEER 13 DEVELOPER 13 TENANT
CONTRACTOR NAME LICENSE NUMBER. LICENSE TYPE BUS. LIC #
t�. 1 Q
COMPANY NAME E-MAIL FAX
,01 _936,
�
STREET ADDRESS CITY, STATE,ZIP PHONE
ARCHITECTIENGINEER NAME LICENSE NUMBER 74(Z BUS.LIC #
COMPANY NAME E-MAIL "� �` FAX
I %%— I N 6 &
41
STREET ADDRESS CITY, STATE, ZIP PHONE
USE OF CI SFD or Duplex Cl Multi-Family PROJECT IN WILDLAND PROJECT IN
STRUCTURE: rzKomsmercial URBAN INTERFACE AREA 0 Yes El No FLOOD ZONE ❑ Yes 0 No
O'SOLAR PANELS ELECTRIC VEHICLE CHARGING STATION 0 SOLAR WATER HEATING OTHER:
FOR SOLAR PANELS., NUMBER OF PANELS/UNITS: KILOWATTS (COMMERCIAL ONLY): 'TOTAL VALUATION:
DESCRIPTION OF WORK
AAL
OWN W
IVED BY:
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 t 9s
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.
Signature of Applicant/Agent: Date: °Z / 11 c6
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
W Q OVER-THE-COUNTER
EXPRESS
STANDARD
< LARGE
wa
P VA,�,�_2 011.doc revised 03116111
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0780
20955 STEVENS CREEK BLVD CUPERTINO,CA 95014-2107(326 31 022) SUSTINEO
CONSTRUCTION
CORPORATION
SAN DIEGO,CA 92119
OWNER'S NAME: DATE ISSUED:06/26/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO;
License Class B C10 046 Lie.4992442
Contractor SUSTINEO CONSTRUCTION CORPORATION Date 04/30/2020 x BLDG_ELECT_PLUMB
MECH- RESIDENTIAL X COMMERCIAL
1 hereby affirm that 1 am licensed under the provisions of Chapter 9(commencing
with Section 7000)of Division 3 of fhe Business&Professions Cade and that my
license is in full force and effect. JOB DESCRIPTION:
WHOLE FOODS T.I.-(N)1440-PANEL ROOF MOUNTED PV
1 hereby affirm under penalty of perjury one of the following two declarations: SYSTEM(496.8 KW)
1. I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided£or by Scauan 3700 of the Labor Code,far the
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 Arca: Valrmtion:$127563.00
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 32631 022
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 Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 06/26/2018 Issued by:Jasmine Archbold
Date:06/26/2018
OWNER-BUILDERCLARATION
1 hereby affirm that 1 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.of is
1. 1,as owner ofdre property,or my employees with wages as their sole installed without fust 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) .
z. 1,ss owner ofthe property,am exclusively contracting with licensed Signature of'Applicane
contractors to construct the project(See.7044,Business&Professions Code), Date:06/26/2018
1 hereby affirm under penalty of perjury one of the fallowing three declarations; ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. 1 have and will maintain a Certificate of Causent to self-inane for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance ofthe work for which this permit is issued HAZARDOUS MATERIALS DISCLOSURE
z I have and will maintain Worker's Compensation Insurance,as provided far by I have read the hazardous naterials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the walk for which this California Health&Safety Code,Sections 25505,25533,and 25534.I will
permit is issued. m aintain 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,l flealth&Safety Code,Section 25532(a)should I store at-handle hazardous
shall not employ n person in an to become subject to the material.Addifionally,should 1 use equipment or devices which emft hazardous
p y a y pe y manner so as J air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of Califmcia.If,after making this certificate of wig 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,Sections 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:06/26!2018
I certify that I have read this application and state that the above information is CONSTRUCTION
correct,I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a constructioY 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.
SignatureLicensed
Date 06/26!2018
Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2018-0780
20955 STEVENS CREEK BLVD CUPERTINO, CA 95014-2107 (326 31 022) SUSTINEO
CONSTRUCTION
CORPORATION
SAN DIEGO, CA 92119
OWNER'S NAME: DATE ISSUED: 06/26/2018
OWNER'S PHONE: PHONE NO: (858) 270-9333
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B. C10. C46 Lic. #992442
Contractor SUSTINEO CONSTRUCTION CORPORATION Date 04/30/2020 X BLDG — ELECT — PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing MECH _ RESIDENTIAL X COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
I hereby affirm under penalty of perjury one of the following two declarations: WHOLE FOODS T.L - (N) 1440-PANEL ROOF MOUNTED PV
SYSTEM (496.8 KW)
1. I have and will maintain a certificate of consent to self-insure for Worker's REV # 1 - REVISION TO ONE LINE DIAGRAM ON SHEET E201 &
Compensation, as provided for by Section 3700 of the Labor Code, for the E110 - ISSUED 12/18/2018
performance of the work for which this permit is.issued.
2. 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
permit is issued. Sq. Ft Floor Area: Valuation: $127563.00
APPLICANT CERTIFICATION
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 32631 022 A (Tenant Improvements)
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 no.n-point
source regulations per the Cupertino Municipal Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature - ,-. Date 12/18/2018 Issued by: Jasmine Archbold
Date: 06/26/2018
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 (See.7044, Business & Professions Code). Date: 12/18/2018
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1. 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. 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. I 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(a) 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 25505, 25533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revolted.
Owner or authorized agent:
APPLICANT CERTIFICATION Date: 12/18/2018
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 works for which this permit is issued (Sec. 3097, Civ C.)
to enter upon the above mentioned property for inspection purposes. (We) agree Lenders 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 ARCH:ITECT'S DECLARATION
Code, Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date 12/18/2018 Professional