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B-2016-2806 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2806 21179 OROGRANDE PL CUPERTINO,CA 95014-4151(362 17 010) WILLOW GLEN ELECTRIC INC SAN JOSE,CA 95155 OWNER'S NAME: BANERJEE ARUNESH AND MOUSHMI DATE ISSUED:10/05/2016 OWNER'S PHONE:650-839-3772 PHONE NO:(408)289-9725 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class C10 Lic.#591918 Contractor WILLOW GLEN ELECTRIC INC Date 04/30/2018 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: I hereby affirm under penalty of perjury one of the following two declarations: (N)EV CHARGING STATION(50 AMP)-GARAGE 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. z. I have and will maintain Worker's Compensation Insurance,as provided for by tlt� Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$990.00 APPLICANT CERTIFICATION J 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 362 17 010 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 regula' s per th Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. ��- Signature, Date 10/05/2016 Issued by:MEL Date: 10/05/201-6--_ - 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 material being installed.If a roof is 2. 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) 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:10/05/2016 '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. 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 the Cupertino Municipal Code,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Coe ecti us 25505,25533,and 25534. Labor Code,I must forthwith comply with such provisions or this permit shall Y be deemed revoked. Owner or authorized agent: 6�1 r APPLICANT CERTIFICATION Date:10/05/2016 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 works for which this permit is issued(Sec.3097,Civ C.) to enter upon the above mentioned properly 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' 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. Licensed Signature Date 10/05/2016 Professional ALTERNATIVE;ENERGY PERMIT APPLICA110N COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 +CUPER`C`IINO (408)777-3228 FAX(408)777-3333•buiidin cu ertino.or PROJECT ADDRESS 17 R 'PRO ° _- APN# N92- 11010 OWNER.NAME /q�`Ell PHONE V C'^ !!. MAIL Aa 1r oil Ioar 4.(f- � e STREET ADDRESS ,;,+)s(/ CITY ST LI9�' �0 FAX CONTACT NAME OC! 6 find r FAX E E-MAIL Mark Londre (408)289-9725 office gwillowq lenelectric.com STREETADDREssR O. Bax 8430 CITY,STATE,ZIP San Jose, CA 95155 FAX(408)289-9725 ❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT 4CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME Mark Londre+ LICENSE NUMBER 591918 LICENSETYPE ^-_lo BUS.LIC# 15897 COMPANYNAME Willow Glen Electric, Inc. E-MAIL off ice @wlllowglenelectrlc.com FAX (408)289-9725 STREETADDRESS P. o. pox 8430 CITY,STATE,ZIP San Jose, CA 95155 PHONE (408)289-9725 ARCHITECT/ENGINEER NAME N/A LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF SFD Or Dup1eX ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ NO SOLAR PANELS I v ELECTRIC VEHICLE CHARGING STATION ❑ SOLAR WATER HEATING ❑ OTHER: FOR SOLAR PANELS. NUMBER OF PANELSIUNITS: KILOWATTS(COMMERCIAL ONLY): TOTAL �7 VALUATION:, 110�® DESCRIPTION OF WORK � ? Electric Vehicle Char in Circuit: 12 P1- - /A)_C Ht,� �fJ �' V RECEIVED BY: 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 beh £ I ha a 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 b gil i, construction. I authorize representatives of Cupertino to enter the above-idpritified property for inspection purposes. Signature of Applicant/Agent: F�' Date: qlZ bl SUPPLEMENTAL INFORMATION REQUIRED OFFICE EISE ONLY x W iBE COU*TER EXPRESS $TANDAR6 Q LARGE,^ W _ 0 MAJOR PVApp_2011.doc revised 03/16111