B-2016-2800 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2800
10198 TONI CT CUPERTINO,CA 95014-2073(316 23 103) WILLOW GLEN
ELECTRIC INC
SAN JOSE,CA 95155
OWNER'S NAME: BALAKRISHNAN ARAVIND AND ARASU VENMAL TRUST DATE ISSUED:09/27/2016
OWNER'S PHONE:408-621-3098 PONE NO:(408)289-9725
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C_10 Lic.#521918
Contractor WILLOW GLEN ELECTRIC INC Date 04/30/2018 XBLDG —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)EV CHARGING STATION(50 AMP)-GARAGE
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.
y z`- 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:$1490.00
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 31623 103
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 ap.licant understands and will comply with all non-point
source regulatio - per �kperti o Municipal Code,Section 9.18. 180 DAYS FRO �LAS��INSPECTION.
=.
.-`
/:-'Signature �� Date 9/27/2016 Issued by:A
Date:09/27/2016
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
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)
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: /29 7/2016
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
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued.
s. 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 an person in an manner so as to become permit
i to the material. Additionally,should I use equipment or devices which emit hazardous
p y y p y 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 C7/6,'
cot 355y, 5533,and 25534.
,z
Labor Code,I must forthwith comply with such provisions or this permit shall nt:
be deemed revoked. ! Owner or authorized age
CONST
APPLICANT CERTIFICATION
Date:9(27/2016 7`r it
I certify that I have read this application and state that the above information is RUCTION 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
I understand my plans shall be used as public records.
Code;Section 9.18.
Licensed
Signature Date 9/27/2016 Professional
ALTERNATIVE ENERGY PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO,,CA 85014-3255
CUPBRTINO (408)777-3228 FAX(408)777-3333-building@cupe6ing.grg
PROJECT ADDRESS J `� ` � ,sed {f� �f e ' AFN#
OWNER NAME /1'°� +"k kt P �H .�f I M 7� �n EPe i t
STREET ADDRESS /� X g;�.yq '' C CITY, STATE,ZIPap- g4 �1
FAX
CONTACT NAME Mark Londre PHONE /408\289-9725 E-MAIL
11 1 / office@willow lenelectric.com
STREET ADDRESsR
O. Box 8430 CITY,STATE,ZIP San Jose, CA 95155 FAX(408)289-9725
❑OWNER 13OWNER-BUILDERO ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECTS ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME Mark Londre LICENSE NUMBER 591918 LICENSE TYPE ^-10 BUS.LIC 11 15897
COMPANY NAME Willow Glen Electric, Inc. E-MAIL officce(—awillowglenelectric.com FAX (408)289-9725
STRF,ETADDRESS R O Box 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 DUpleX ❑ MUlti-Family PROJECT IN WILDLANDPROJECT IN
STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes t NO FLOOD ZONE ❑ Yes L911N0
❑SOLAR PANELS 1!►J ELECTRIC VEHICLE CHARGING STATION ❑ SOLAR WATER HEATING ❑ OTHER: ��
FOR SOLAR PANELS. NUMBER OF PANELS/UNITS: KILOWATTS(COMMERCIAL ONLY): TOTAL VALUATION:11/j*ay""�a 0
[[
DESCRIPTION OF WORK
Electric Vehicle Charging Circuit: db e c et4.e-,t
1 CzW, 46,1e_ jam&
X-4-
RECEIVEVEY: �°$
au L4�LUL ,
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 b hal£ I h ve 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.
Signature of Applicant/Agent: 'r �L4� Date: "`
SUPPLEMENTAL INFORMATION REQUIRED QMCE USE tfty
CI OVER-THE-COUNTER
{� EXPRESS
v PAV' ❑ SI ANDARD
❑'LARGE
❑ MAJOR
PVApp_2011.doc revised 03/16111