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BLD-2021-0802_SignedPermiCITY OF BUILDING PERMIT CITY HALL 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 PHONE 408-777-3228 CUPERTINO WWW.CUPERTINO.ORG BUILDING ADDRESS: 1106 DERBYSHIRE DR APN: 362 21 038 PERMIT NO: BLD-2021-0802 OWNER'S NAME: CONTRACTOR: TESLA ENERGY OPERATIONS INC CONTRACTOR PHONE: DATE ISSUED: Dec 16,2021 ISSUED BY: Phuong Devries, P.E. VALUATION: 21000 JOB DESCRIPTION: INSTALL (27) PANELS ROOF MOUNTED PC SYSTEM (8.16 KW); NEW (2) POWERALL STORAGE SYSTEM; NEW 200 LOAD CENTER REV#1 - ROOF LAYOUT AND EQUIPMENT LOCATION HAS BEEN CHANGED. APPROVED 7.7.21. LICENSED CONTRACTOR'S DECLARATION: NO: EXP DATE: 12/31 /2022 888104 7000) of Division 3 of the Business & Professions CONTRACTOR: LICENSED CLASS: GENERALR B LICENSED TESLA ENERGY OPERATIONS INC BUILDINGC10 ELECTRICAL, C39 I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section Code and that my license is in full force and effect. as provided for by Section 3700 of the I hereby affirm under penalty of perjury one of the following three declarations: ❑ I have and will maintain a certificate of consent to self -insure for Worker's Compensation, Labor Code, for the performance of the work for which this permit is issued. Section 3700 of the Labor Code, for the not employ any person in any manner so as to this certificate of exemption, I become subject to with such provisions or this permit shall be I. I have and will maintain Worker's Compensation Insurance, as provided for by performance of the work for which this permit is issued. ❑ I certify that in the performance of the work for which this permit is issued, I shall become subject to the Worker's Compensation laws of California. If, after making the Worker's Compensation provisions of the Labor Code, I must forthwith comply deemed revoked. HAZARDOUS MATERIALS DISCLOSURE & Safety Code, Sections 25505, 25533, and 25534. I M I have read the hazardous materials requirements under Chapter 6.95 of the California Health will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or air contaminants as defined by the Bay Area Chapter 9.12 and the Health & Safety Code, handle hazardous material. Additionally, should I use equipment or devices which emit hazardous Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Sections 25505, 25533, and 25534. EPA LEAD -SAFE DISCLOSURE No: ❑ An EPA Lead -Safe Certified Renovator will be responsible for this project. Certified Firm Name: Firm Certification ✓ No EPA Lead -Safe Certified Firm is required for this project. CONSTRUCTION LENDING AGENCY of the work which this permit is issued I hereby affirm under penalty of perjury that there is a construction lending agency for the performance (Section AV7, Civil Code). Yes El No Lender's Name: Lender's Address: APPLICATION CERTIFICATION with all city and county ordinances and state the above mentioned property for inspection judgements, costs, and expenses which may understands and will comply with all non -point I certify that I have read this application and state that the above information is correct. I agree to comply laws relating to building construction, and hereby authorize representatives of this city to enter upon purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, accrue against said City in consequence of the granting of this permit. Additionally, the applicant source regulations per the Cupertino Municipal Code, Section 9.18. Signature `" Z� I"a,i_ Date Dec 16, 2021 EVERY PERMIT ISSUED SHALL BECOME INVALID UNLESS THE WORK ON THE SITE AUTHORIZED BY SUCH PERMIT IS COMMENCED WITHIN 365 DAYS AFTER ITS ISSUANCE, OR IF THE WORK AUTHORIZED ON THE SITE BY SUCH PERMIT IS SUSPENDED OR ABANDONED FOR A PERIOD OF 365 DAYS AFTER THE TIME THE WORK IS COMMENCED. BUILDING PERMIT CUPERTINO CITY HALL 10300 Torre Avenue • Cupertino, CA 95014-3255 PHONE 408-777-3228 WWW.CUPERTINO.ORG BUILDING ADDRESS: 1 106 DERBYSHIRE DR Cupertino APN: 362 21 038 PERMIT NO: BLD-2021-0802 OWNER'S NAME: CONTRACTOR: TESLA ENERGY OPERATIONS INC, 901 PAGE AVE,ATTN LICENSING FREMONT CONTRACTOR PHONE: DATE ISSUED 5/12/2021 3:41:34 PM ISSUED BY: PhuongD VALUATION: $21000 JOB DESCRIPTION (1) POWERALL STORAGE SYSTEM; NEW 200 LOAD CENTER INSTALL (27) PANELS ROOF MOUNTED PC SYSTEM (8.16 KW); NEW LICENSED CONTRACTOR DECLARATION ROOFING, C36 PLUMBING 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full CONTRACTOR: LICENSED C46 LICENSED EXP 12/31/2022 I hereby force I hereby CLASS: SOLAR, B GENERAL NO: 888104 DATE: affirm and effect. affirm I have and for which I have and I certify that with TESLA ENERGY OPERATIONS INC BUILDING CONTRACTOR, C10 ELECTRICAL, C39 that I am licensed under the provisions of Chapter under penatiy of perjury one of the following three will maintain a certificate of consent to self -insure this permit is issued. will maintain Worker's Compensation Insurance, in the performance of the work for which this laws of California. If, after making this certificate such provisions or this permit shall be deemed revoked. declarations: for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith V issued. Compensation comply HAZARDOUS MATERIALS DISCLOSURE Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance I have read the hazardous materials requirements under the Cupertino Municipal Code, Chapter 9.12 and the Health V with equipment Municipal & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Sections 25505, 25533, and 25534. or devices which emit hazardous air contaminants Code, Chapter 9.12 and the Health & Safety Code, EPA LEAD -SAFE DISCLOSURE for this project. Firm Certification No: An EPA Lead -Safe Certified Renovator will be responsible Firm Name: No EPA Lead -Safe Certified Firm is required for this project. Certified V CONSTRUCTION LENDING AGENCY lending agency for the performance of the work which this permit is issued (Section 3097, Civil Code). Lender's Address: I hereby Yes affirm under penalty of perjury that there is a construction No V Lender's Name: APPLICATION CERTIFICATION information is correct. I agree to comply with all city and county ordinances and state laws relating to building to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, regulations per the Cupertino Municipal Code, Section 9.18. I certify that I have read this application and state that the above construction, and hereby authorize representatives of this city harmless the City of Cupertino against liabilities, judgements, costs, the applicant understands and will comply with all non -point source Signature: Every permit issued shall become invalid unless the work on the site authorized by such permit is commenced within 365 days after its issuance, or if the work authorized on the site by such permit is suspended or abandoned for a period of 365 days after the time the work is commenced. BUILDING PERMIT CUPERTINO CITY HALL 10300 Torre Avenue • Cupertino, CA 95014-3255 PHONE 408-777-3228 WWW.CUPERTINO.ORG BUILDING ADDRESS: 1 106 DERBYSHIRE DR Cupertino APN: 362 21 038 PERMIT NO: BLD-2021-0802 OWNER'S NAME: CONTRACTOR: TESLA ENERGY OPERATIONS INC, 901 PAGE AVE,ATTN LICENSING FREMONT CONTRACTOR PHONE: DATE ISSUED 5/12/2021 3:41:34 PM ISSUED BY: PhuongD VALUATION: $21000 JOB DESCRIPTION (1) POWERALL STORAGE SYSTEM; NEW 200 LOAD CENTER INSTALL (27) PANELS ROOF MOUNTED PC SYSTEM (8.16 KW); NEW LICENSED CONTRACTOR DECLARATION ROOFING, C36 PLUMBING 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full CONTRACTOR: LICENSED C46 LICENSED EXP 12/31/2022 I hereby force I hereby CLASS: SOLAR, B GENERAL NO: 888104 DATE: affirm and effect. affirm I have and for which I have and I certify that with TESLA ENERGY OPERATIONS INC BUILDING CONTRACTOR, C10 ELECTRICAL, C39 that I am licensed under the provisions of Chapter under penatiy of perjury one of the following three will maintain a certificate of consent to self -insure this permit is issued. will maintain Worker's Compensation Insurance, in the performance of the work for which this laws of California. If, after making this certificate such provisions or this permit shall be deemed revoked. declarations: for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith V issued. Compensation comply HAZARDOUS MATERIALS DISCLOSURE Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance I have read the hazardous materials requirements under the Cupertino Municipal Code, Chapter 9.12 and the Health V with equipment Municipal & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Sections 25505, 25533, and 25534. or devices which emit hazardous air contaminants Code, Chapter 9.12 and the Health & Safety Code, EPA LEAD -SAFE DISCLOSURE for this project. Firm Certification No: An EPA Lead -Safe Certified Renovator will be responsible Firm Name: No EPA Lead -Safe Certified Firm is required for this project. Certified V CONSTRUCTION LENDING AGENCY lending agency for the performance of the work which this permit is issued (Section 3097, Civil Code). Lender's Address: I hereby Yes affirm under penalty of perjury that there is a construction No V Lender's Name: APPLICATION CERTIFICATION information is correct. I agree to comply with all city and county ordinances and state laws relating to building to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, regulations per the Cupertino Municipal Code, Section 9.18. I certify that I have read this application and state that the above construction, and hereby authorize representatives of this city harmless the City of Cupertino against liabilities, judgements, costs, the applicant understands and will comply with all non -point source Signature: Every permit issued shall become invalid unless the work on the site authorized by such permit is commenced within 365 days after its issuance, or if the work authorized on the site by such permit is suspended or abandoned for a period of 365 days after the time the work is commenced. ...BUILDING PERMIT CITY HALL 10300 Torre Avenue • Cupertino, CA 95014-3255 PHONE 408-777-3228 WWW.CUPERTINO.ORG BUILDING ADDRESS: 1106 DERBYSHIRE DR Cupertino APN: 362 21 038 PERMIT NO: BLD-2021-0802 OWNER'S NAME: CONTRACTOR: TESLA ENERGY OPERATIONS INC, 901 PAGE AVE,ATTN LICENSING FREMONT CONTRACTOR PHONE: DATE ISSUED 5/12/2021 3:41:34 PM ISSUED BY: PhuongD VALUATION: $21000 JOB DESCRIPTION INSTALL (27) PANELS ROOF MOUNTED PC SYSTEM (8.16 KW); NEW (1) POWERALL STORAGE SYSTEM; NEW 200 LOAD CENTER24 LICENSED CONTRACTOR DECLARATION CONTRACTOR: TESLA ENERGY OPERATIONS INC LICENSED CLASS: C46 SOLAR, B GENERAL BUILDING CONTRACTOR, C10 ELECTRICAL, C39 ROOFING, C36 PLUMBING LICENSED NO: 888104 EXP DATE: 12/31/2022 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 penatly of perjury one of the following three declarations: ihave to for Worker's Compensation, for by Section 3700 the Labor Code, for the the and will maintain a certificate of consent self -insure as provided of performance of work f• . ich this permit is issued. Elhave Worker's Compensation Insurance, for by Section 3700 the Labor Code, for the the for this is and will maintain as provided of performance of work which permit d. that in the the for this is issued, I in to become to the Worker's Compensation comply certify performance of work which permit shall not employ any person any manner so as subject laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith with such provisions or this permit shall be deemed revoked. HAZARDOUS MATERIALS DISCLOSURE V I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment Municipal or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. EPA LEAD -SAFE DISCLOSURE rin EPA Lead Certified Renovator be for this -Safe will responsible project. Certified Firm Name: tee Firm Certification No: No EPA Lead -Safe Certified Firm is required for this project. CONSTRUCTION LENDING AGENCY I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work which this permit is issued (Section 3097, Civil Code). Yes te No Lender's Name: Lender's Address: APPLICATION 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 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 indemnify and keep harmless the City of Cupertino against liabilities, judgements, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature: Every permit issued shall become invalid unless the work on the site authorized by such permit is commenced within 365 days after its issuance, or if the work authorized on the site by such permit is suspended or abandoned for a period of 365 days after the time the work is commenced.