BLD-2022-0900_SignedPermit.pdfCITY OF
BUILDING PERMIT
CITY HALL
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
PHONE 408-777-3228
CUPERTINO WWW.CUPERTINO.ORG
BUILDING ADDRESS: 10828 SYCAMORE CT APN: 342 57 031
PERMIT NO: BLD-2022-0900
OWNER'S NAME:
CONTRACTOR: TESLA ENERGY OPERATIONS INC
CONTRACTOR PHONE:
DATE ISSUED: 2022-05-23 ISSUED BY: Haley McKee VALUATION: 14000
JOB DESCRIPTION: INSTALL (N) ENERGY STORAGE SYSTEM - (2) POWERWALLS ON EXTERIOR
WALL (27KWH); (N) TESLA BACKUP GATEWAY WITH LOAD CENTER (200AMP);
(N) DISTRIBUTION PANEL (225 AMP).
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 BUILDING,C10
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
2022
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 Rath- Y G Date May 23,
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.
BldgApp_2017.doc revised 01/01/21
APN #
OWNER NAME PHONE E-MAIL
STREET ADDRESS CITY, STATE, ZIP
CONTACT NAME
CITY, STATE, ZIP
OWNER
OWNER-BUILDER
OWNER AGENT CONTRACTOR AGENT ENGINEER DEVELOPER TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE COMPANY NAME
E-MAIL
STREET ADDRESS CITY, STATE, ZIP PHONE
STORIES #USE TYPE OCC SQ.FT. VALUATION ($) NEW FLOOR SF DEMO SF TOTAL NET SF
REMODEL KITCHEN
SF
REMODEL OTHR
PORCH SF DECK SF
ATTACHEDDWELLING
UNITS #
YES EICHLER NO
RECEIVED BY:
TOTAL VALUATION:
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.
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • permitcenter@cupertino.org
B
EXISTING ROOF TYPE: BUILT-UP ROOF ASPHALT SHINGLES WOOD SHAKES WOOD SHINGLES OTHER (SPECIFY) ___________________
NO
YES
REMOVE /REPLACE IF NO
# OF LAYERS________
PLYWOOD ½” PLYWOOD TYPE:
THICKNESS CDX OTHER____________
PITCH: _____ :12 ROOF CLASSA
RE-ROOF
WOOD SHINGLES OTHER _____________
*HOA-Provide a letter of approval from the Home Owner's Association
SF __________ #of SQUARES ___________
NEW CONSTRUCTION ADDITION
EXISING
FIRE SPRINKLERS
YES
NO
SINGLE-FAMILY/DUPLEX MULTI-FAMILY INDUSTRIAL COMMERCIAL
SECOND STORY ADDITION
VINYL-LINEDFIBERGLASS GUNITE PREFABRICATED
Commercial or Multi-Family Buildings with Public Swimming Pools requires Department of Environmental Heath approval
POOL - SF _______ SPA - SF _______
ALTERATION T.I.MEP
DESCRIPTON
DETACHED
YES
NO
SF
SECOND DWELLING
UNIT ADDITON:YES
NO
DETACHED
POOLS
TILE
OTHER__________
OSB
OTHER
STREET ADDRESS
PROJECT ADDRESS
E-MAIL PHONE BUS. LIC #
ARCHITECT
ATTACHED
S F ____________
TOTAL - SF __________SPA ATTACHED YES NO
EXISTING USE EXISTING SF
GARAGE
SF
REMODEL
BATHROOM SF
5/8”
WOOD SHAKES PROPOSED ROOF TYPE: BUILT-UP ROOF ASPHALT SHINGLES
*Provide a signed copy of the Cupertino’s Tear-Off Policy
3/8”
RE-ROOF
PERMIT #B - __________ - __________
SWIMMING POOL/SPA