B-2018-0722 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0722
22630 SAN JUAN RD CUPERTINO,CA 95014-3989(342 18 004) TESLA ENERGY
OPERATIONS,INC.
SAN MATEO,CA 94402
OWNER'S NAME: DATE ISSUED:04/30/2018
OWNER'S PHONE: PHONE NO:(650)967-5100
LICENSED T DECLARATION BUILDING PERMIT INFO:
License Class 8 C10 C46 Lic.#888104
Contractor TESLA ENERGY OPERATIONS,INC.Date 12/31/2018 X BLDG ELECT_PLUMB
1 herebyaffirm that I am licensed under the revisions of Chapter 9 —MECH X RESIDENTIAL_COMMERCIAL
a P p (commencing
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
(N)15-PANEL ROOF MOUNTED PV SYSTEM-(4,875 KW)
I hereby affirm under penalty of perjury one of the following five declarations:
r. 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 o£the work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Cade,for the performance of the work for which this
permit is issued. Sq.Ft Fluor Area: Valuation:$7215.00
APP LI CANT CERTIFICATION
I certify that I have read this application and slate that the above
information is correct.I agree to comply with all city and county ordinances All Number: Occupancy Type:
and stale laws relating to building construction,and hereby authorize 342 18004
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 LSA DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regul ons per the Cupertino Municipal Code,Section 9.16. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 04/3012018 Issued by:Jasmine Archbold
Date:04/30/2018
OWNER-BUILDER DECLARATION
I hereby aMr.that I nm exempt front the Contractor's License Law for ane of theRE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.Its roof'is
r. 1,as owner of the property,or my employees with wages as their sole installed without first obtaining an inapcction,I agree to remove all new materials for
compensation,will do the work,and the structure Is not intended or offered for inspwfioa
sale(Sce.7044,Business&Professions Cade)
z. 1,as owner of the property,am exclusively contracting with licensed Signature ofApplicanh
contractors to construct the project(See.7044,Business&Professions Code). Date:04/30/2018
1 hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
t. 1 hove 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 ofthe work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
i. 1 have and will maintain Worker's Compensation insurance,as provided for by I have read the hazardous materials r,9 uirrourrits under Chapter 6.95 of the
Seoion 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534.1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
a. 1 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 son in an manner so as to become subject to the material.Additionally,should 1 use equipment or devices which emit hazardous
p y any per y 1 m contaminants as dented by the Day Arun Air Quality Management District i
Worker's Compensation laws of California.If,alter making chis ceitifcate of will an
afntain 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 Cad Se tions 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorizetl agent:
APPLICANT CERTIFICATION Date:0413 0/2 01 8
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 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
Data 04130/2016
Professional