B-2016-2519 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: CONTRACTOR: PERMIT NO:B-2016-2519
6059 BOLLINGER RD CUPERTINO,CA 95014-4629(375 38 005) SOLAR CENTER INC_
MENLO PARK,GA
94025
OWNER'S NAME' LISTER PATRICK M ET AL DATE ISSUED:08/15/2016
OWNER'S PHONE:818-530-6567 PHONE NO:(650)327-3200
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class GLAZING Lic.#488066
Contractor SOLAR CENTER INC Date 03/31/2018_ X_BLDG _ELECT PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 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)11 PANEL;ROOF MOUNTED PV SYSTEM(3.135W)
I hereby affirm under penalty of perjury one of the following two declarations:
1. 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.
,//II�-have and will maintain Worker's Compensation Insurance,as provided for by
6-Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$10000.00.
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 375 38 005
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 regulat' jr the Cupertino Municipal Code,Section 9.18.. 180 DAYS FROM LAS LED INSPECTION.
Signatur Date 08/15/2016 Issued by: L AN
Date:08/15/2016
0" /11
ER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RF-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:08/15/2016
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. Lcertify 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 C Sections 25505,2 33,and 25539.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revokedOl
wner or authorized ag ,
APPLICANT CERTIFICATION Date:0811512016
1 certify that I have read this application and state that the above information is C0&9TR41CTION LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws 1 hereby affirm that t§res 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 ARCHITECT'S DECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal
Code,Section 9.18. 1 understand my plans shall be used as public records.
SiSignature Date 08/15/2016 Licensed
9 Professional
ALTERNATIVE ENERGY PERMIT APPLICATION'
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10306 TORRE.AVENUE•CUPERTINO, CA 95014-3255'
(408)777-3228•FAX(408)777-3333•building(a)_cupertino.org
CGPERfINO
PROJECT ADDRES f A APN# 3 :?,Rr r Jr o
OVINEANA_ME pP� PHO vEE-MAIL V
STREET ADDRESS CITY,STATE,ZIP FAX
CONTACT NAME PHONE E-MAIL
STREET ADDRESSCITY,STATE,ZIP '
❑OwNER ❑ OWNER-BUII.DER ❑ OWNERAGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT 0 ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICE-14,P BBEIj,( LICENSE STYPE �CLIC#
COMPANY NAME / f�E-MAIL `� FA} p
STREET ADDRESS r®�ysr ® C STATE,ZIP � ® FI 3Z--'7--3
�0
ARCHITECT/ENGINIEER(f"NAME LICENSE NUMBER 6� BUS..LIC#
COMPANY NAME E-MAIL I'AX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF Sl~D Or DupleX ❑ Multi-Family PROJECT IN WILDLAND PROSECT IN
STRUCTURE ❑ COTm?Iercial� URBAN INTERFACE AREA ❑ Yes i N0 FLOOD.ZONF. ❑ Yes p,( ,NO ..
IOLAR PANELS :TO ELECTRIC VEHICLE CHARGING STATION ❑ SOLAR WATER HEATING ❑ OTHER:
FOR SOLAR PANELS.- NUMBER OF PANELS/UNITS: �A KILOWATTS(COMMERCIAL ONLY): 3` /3 ,. TOTAL VALUATION:
DESCRIPTION OF WORK �,.J`��
_
By my signature below,I certify to each of the following: I am the property owner or authorized agen
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. to comply with all applicable local
ordinances and state laws relating wilding constructs u orize,represcmatives of Cupertino to enter the above-1 entified property for inspection purposes.
Signature of Applicant/Agent: Date: —
UPPLEMENTAL INFORMATION REQUIRED `
OFFICE ITSE OIyLY
n
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