B-2017-2019 • CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-2019 '
10759 JUNIPER CT CUPERTINO,CA 95014-6556(342 57 013) COBALT POWER
SYSTEMS INC
MOUNTAIN VIEW,CA
94043
•
OWNER'S NAME: BERGENDAHL JASON R TRUSTEE&ET AL • DATE ISSUED:11/22/2017
OWNER'S PHONE:408-836-7722 PHONE NO:(650)938-9574
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-10 Lic.#820697
Contractor COBALT POWER SYSTEMS INC Date 06/30/2019 X BLDG _ELECT PLUMB
MECH X RESIDENTIAL_COMMERCIAL
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. JOB DESCRIPTION:
(N)22-PANEL ROOF MOUNTED PV SYSTEM(7.04 KW)
I hereby affirm under penalty of perjury one of the following two declarations:
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.
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:$28000.00
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 342 57 013
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.
"Sig Date 11-22-2017 Issued by:Kim Dunbar
.111101 Date: 11/22/2017
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'niaterial 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(Scc.7044,Business&Professions Code)
' z. 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: 11-22-2017
I hereby affirm under penalty of perjury one of the following three declarations: „ „ ;�:3
1. I have and will'maintain a Certificate of Consent to self-insure for Worker's ALL ROOF COVERINGS TO BE CLASS A OR BETTER
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 isued. 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'tlte Cupertino Municipal Code,Chapter 9.12 and
exemption,Lbecome 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 revoked. Owner or authorized -41-
APPLICANT CERTIFICATION Date: - -20 7
I certify that I have read this application and state that the above information is • ION 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 nbn-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. I understand my plans shall be used as public records.
Licensed
Signature Date 11-22-2017 Professional
`L\\ / ALTERNATIVE ENERGY PERMIT APPLICATION AE
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
/�.,,yy.,,
\„, 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO•
(408)777-3228•FAX(408)777-3333•buildinq a cupertino.orq
D - Zoll- r W fq
PROJECT ADDRESS 10 9 ,n 1 p.e Y Co u -t APN# ,3 cti...„- .-0 13
OWNER NAME 5-ey OJf rY cl CJS h 1 PHON
CCLf g56,-7�LZ E-MAIL
STREET ADDRESS ,;✓/ ✓ CITY,STATE,ZIP FAX
CONTACT NAME Tatiana Hairno PHONE 650-417-5178: E-MAItatianah@cobaltpower.com
STREET ADDRESS 2557 Wyandotte Street CITY,STATE,ZIP Mountain View, CA 94043 FAX 650-938-9573 ,
❑:OWNER 0 OWNER-BUILDER El1 OWNER AGENT 0 CONTRACTOR 0 CONTRACTOR AGENT 0 ARCHITECT 0 ENGINEER 0 DEVELOPER 0 TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. I
CONTRACTOR
Cobalt Power'Systems Inc. 820697 C-10 O3' ss— '
CGMPANYNAMECobalt Power'Systems Inc. E-MAINtatianah@cobaltpower.corn FAX
STREETADDRESS 2557 Wyandotte Street CITY,STATE,ZIP Mountain View, CA 94043 PHONE'650-93879574
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS:LIC# : 1 ,1
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF X SFD or Duplex 0 Multi-Family PROJECT IN WILDLAND PROJECT IN
STRUCTURE: 0 Commercial URBAN INTERFACE AREA 0 Yes ID No FLOOD ZONE 0 Yes' 0 No
Pti SOLAR PANELS 0 ELECTRIC VEHICLE CHARGING STATION 0 SOLAR WATER HEATING 0 OTHER: ,
FOR SOLAR PANELS: NUMBER OF PANELS/UNITS. Z Z KILOWATTS(COMMERCIAL ONLY): TOTAL VALUATION: $ a g 1000.00
DESCRIPTION OF WORK .'TvA.s 1( 1 014 kw ?N1{ So a-Y on Yoo C. ..
.
I
I
1. it ' ..
RECEI 4Q/44
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 con truction. I authorize representatives of Cupertino to enter the above-i entified property,for inspection purposes.
Signature of Applicant/Agent: 1,Ir1-O Date: 0 2-2- (
j j SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
W ❑.OVER-THE-COUNTER
w
❑ EXPRESS '
/1")"` g 0 STANDARD
.4• 0LARGE
Pr
❑ MAJOR
PT41pp_2011.doc revised 03/16/11