B-2016-2347CITY OF CUPERTINO BUILDING PERMIT
BURDINGADDRESS:
CONTRACTOR:
PERMIT NO: 972016-2347
19920 OLIVEWOOD ST CUPERTINO, CA 95014-600 (316 43 004)
CAMERON ELECTRIC
NAPA, CA 94558
OWNER'S NAME: ESSEX THE POINTE LP
DATE ISSUED- 11/18/2016
OWNER'S PHONE: 650-494-3700
PHONE NO: (707j 287-4938
LICENSED COMRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class C-10 Lic. #$50835
Contractor CAMERON ELECTRIC Date 12/31/2016
X_ BLDG —ELECT — PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
— MECH X RESIDENTIAL — COMMERCTAT"
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
(I) EV CHARGING STATION (40 AMPS) - PARKING LOT
I hereby affirm under penalty of perjury one of the following two declarations:
i. 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.
Aa%z %f I have
and will maintain Worker's Compensation Insurance, as provided for by
Jf "
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
Sq. Ft Floor Area:
Valuation: $6000.00
APPLICANT RTIFI ATION
certify that I have read this application and state hat the above
Number:
panc y TYPe,:
Occupancy
information is correct. I agree to comply with all cityand countordinances
and state laws relating to building construction, and hereby authorize
43 00 4
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.
Additionally, the applicant understands and will comply with all non -point
WITffiN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cupertino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
/ s�
Signature Date 11/18/2016
Issued by: Abby Ave nde
Date: 11/18/2016
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. L 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: 11/18/2016
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
i. 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. 1 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. 1 certify that in the performance of the work for which this permit is issued, I
Health & Safety Code, Section 25532(x); 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
Worker's Compensation laws of California. If, after making this certificate of
air contaminants as defined by the Bay Area Air Quality Management District I
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 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 agent: @i/i?ecz
C
APPLICANT CERTIFICATION
Date: 11/18/2016
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.
Signature Date 11/18/2016
Licensed
Professional
UPERTINO
ALTERNATIVE ENERGY PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014=3255
(408) 777-3228 • FAX (408) 777-3333 • buildinggggpertino.ong
PROJECT ADDRESS V 6J0 APN#
OWNER NAME PHONE E-MAIL
l•`J� Y ��, i ; CITY, STATE, ZIP 0144 0
STREETADDRESS C� 111»> VY 1� `Attu, CA FAX
CONTACT NAME'SCA 1 O 0, � r PHONE v E-MAIL
STREET ADDRESS Y Y l i CITY, STATE, ZIP
FAX
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❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑. DEVELOPER ❑ TENANT
CONTRACTOR NAME,rk �L� chmr r L,C ISENUMBER LICENSE TYPE BUS. LIC #
lu
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COMPANY NAME E-MAIL CilL�Y��SG� FAX
STREET ADDRESSq1K�: CITY, STATE, PHONE -7fh( , a �+(� c Z,2,6ARCHITECT/ENGI NEER NAME LICENSE NUMBER BUS. LIC #
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY, STATE, ZIP PHONE
USE OF ❑ SFD or Duplex Multi -Family PROJECT IN WILDLAND PROJECT IN
STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ No
❑ SOLAR PANELS 7 ELECTRIC VEHICLE CHARGING STATION ❑ SOLAR WATER HEATING El OTHER:
)
FOR SOLAR PANELS. NUMBER OF PANELS/CIN(COMMERCIAL ONLY: TOTAL, KILOWATTS • VALUATION: IIJJ
1�
DESCRIPTION OF WORK
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. -1 have r1ad this
application and the infonnation 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 pro for for inspection purposes.
Signature of Applicant/Agent: Date
SUPPLEMENTAL INFORMATION REQUIRED >" w2,. OFFIcEuSEirn
PVApp_2011.doe revised 03116/11