B-2017-0008CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2B124Hft
21438 KRZICH PL CUPERTINO, CA 95014-4943 (362 06 038) WILLOW GLEN
ELECTRIC INC
SAN JOSE, CA 95155
OWNER'S NAME: RAO FAN AND LN XIAOYI TRUSTEE
OWNER'S PHONE: 408-306-0995
LICENSED ONTRA TOR' DECLARATION
License Class C-10 Lic. #591918
Contractor WILLOW GLEN ELECTRIC, INC Date 04/30/2018
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.
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.
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.
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
and state laws relating to building construction, and hereby authorize
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
may accrue against said City in consequence of the granting of this permit.
Additionally, the applicant understands and will comply with all non -point
source regulations per the Cupertino Municipal Code, Section 9.18.
Date 01/03/2017
ISSUED: 01/03/2017
PHONE NO: (408) 289-9725
BUILDING PERMIT INFO:
BLDG X ELECT _ PLUMB
MECH X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION:
(N) EV CHARGING STATION (15 AMPS) W/SUB-PANEL (40 AMP)
Sq. Ft Floor Area: I Valuation: $2560,50
"N Number: Occupancy Type:
362 06 038
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: Kim Dunbar
Date: 01/03/2017
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
t. 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)
I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three 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.
2. 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.
s. I certify that in the performance of the work for which this permit is issued, I
shall not employ any person in any manner so as to become subject to the
Worker's Compensation laws of California. If, after making this certificate of
exemption, I become subject to the Worker's Compensation provisions of the
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
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 and state laws
relating to building construction, and hereby authorize 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 may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands
and will comply with all non -point source regulations per the Cupertino Municipal
Code, Section 9.18.
Signature Date 01/03/2017
Signature ofApplicant:
Date: 01/03/2017
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance. with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Munici A Code C apter 9.12 and
the Health & Safety Code, Sections 2550 25533, 25534.
Owner or authorized age
Date: 01/03/2017
TION LENLRiG AGENCY
I hereby affirm that there is a construction lending agency for the performance
of work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
CUPCRTINO
ALTERNATIVE ENERGY PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 . FAX (408) 777-3333 • kjtli ril ,IWi-) Lilit;;
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PROTECT ADDRESS6 , f 3e /� a I
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APN #
OWNER NAME 14 o /
PHONE ;, .3011-
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E-MAIL S�[ l a 09� Cdt,0C a �'
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STRP_ET ADDRESS/ ) T 1 *q �s:CdaA7 Y a
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FAX , s
CONTACT NAME Mark Londre
PHONE (408)289-9725
E-MAIL
office @willow lenelectric.corn
STREET ADDREssR
0. Box v 8430
CITY, STATE, ZIP San Jose, CA 95155
FAX (408)289-9725
❑ OWNER El OWNER -BUILDER ❑VOWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME Mark Londre
LICENSE NUMBER 591918
LICENSETYPE ^-10
BUS'. LIC II 15897
COMPANY NAME ,Willow Glen Electric, Inc.
E-MAIL office@willowgienelectric.com
FAX (408)289-9725
STREET ADDRESS P. o. Box 8430
CITY, STATE, ZIP San Jose, CA 95155
PHONE (408)289-9725
ARCHITECT/ENGINEER NAME N/A
LICENSE NUMBER
BUS. LIC #F
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF VfSFD or Duplex ❑ Multi-Farnily
STRUCTURE: ❑ COrnrilerCtal
PROJECT IN WILDLAND
URBAN INTERFACE AREA ❑Yes ❑ NO
PROJECT IN
FLOOD ZONE ❑ Yes ❑ No
❑ SOLAR PANELS
ELECTRIC VEHICLE CHARGING STATION TO
SOLAR WATER HEATING
❑ OTHER:
FOR SOLAR PANELS: NUMBER OF PANELS/UNITS: KILOWATTS (COMMERCIAL ONLY):
TOTAL VALUATION:
�I1 J
DESCRIPTION OF WORK .M (7 3 I g
Electric Vehicle Char in Circuit: Plkh ei3 5 rl V �
i tz-:7 ,
f
R, D Y,
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 cons ti p fI- m tho i rep tatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: !(4\\\ Date:
SUPPLEMENTAL INFORMATION REQUIRED
OFMCE USE ONLY
OVER-THE-COUINTER
❑ EXPRESS: .
❑. ;STANDARD .
0 LARGE
❑ MAJOR
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SMOKE/ CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
COMMU
NITY DEVELOPMENT DEPARTMENT -BUILDING DIVISION
103,00 TORRE AVENUE - CUPERTINO, CA 95014-3255-
CUPERTINO (408) 777-3228 - FAX (408) 777-3335 - bu-ildingacupertino.orp OCO
Pere N0.B-2017zP__36
Address 21438 Krzich Place, Cupertino #of Alarms Smoke: 4 _ Carbon Monoxide: 4
PERMIT CANNOT BFFINALED AND -COMPLETED tMM TH18 CE, RTIFICATE
HAS BE, ENSjQZjR AND REnMMD TO THEBUILDING DIN71SION
PURPOSE
This affidavit is a -self-certification for the installation of all -required Smoke and Carbon Monoxide Alarms for
compliance with 2013 CRC Section R314,2013 CBC Sections 420.6 and 907.2,11.2 where no interior access for
inspections are required.
GENERAL INFORMATION
Existing single-family and multi -family dwellings shall be provided with Smoke Alarms and Carbon
Monoxide alarms. When the valuation of additions, alterations, Or repairs to existing dwelling -units exceeds
$1000,00, CRC Section 1 314 and CDC Sections 907.2.11,5 and 420.6 require that Smoke Alarms and/or Carbon
Monoxide Alarms be installed in the following locations:
AREA
SMOKE NLAIW
CO ALARM
Outside of each separate sleeping area in the immediate vicinity of the
bedroom(s)
X
X
— -----
On every levet Ifingunit in basements
a dwe cluding
X
X
Within each sleeping room
_x
Carbon Monoxide alarims are not required in dwellings which do not contain fuel -burning appliances and that
do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with
CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal.
Power Supply: In dwelling units with no commercial power supply, alarm(s) may be solely battery operated.
In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do
not result in the removal of wall and ceiling finishes or there is no access by means of attic, basement or crawl
space, Refer to CRC Section 8314 and CBC Sections 907.2.11.4 and 420,6.2. An electrical permit is required for
alarms which must be connected to the building wiring.
As owner of the above -referenced property, I hereby certify that the a] arm(s) referenced above has/have been
installed in accordance with the manufacturer's instructions and in compliance with the California Building
and California Residential Codes. The alarms have been tested and are operational, as of the date signed
below.
I have read and amee W cornPty with the terms and conditions of this statement
owner (or Owner Anger Vs) Name: Docuftned by*
15/201
xi aoYi Li U -SKianau .'X,014ijiy. ..... ........ ............................ .... . ..
t, r �.
Contractor Name: 6F94C9EEC5F6418_
si rlatSdrL. ......... ............ Date: - — ---_--_-
S"joke,a,ld C0fr.,rjjjdoc r-evised 03118114
uocu6ign Envelope ID: 87B26810-BDBA-493D-8615-5C89EB772506
AM algaoil"Wal
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 177-3333 - bOi dingO6upertino.org
Owner Name 'XiaoYi Liu. Permit No B-2017-3336
Address 21438 Krzich Place, Cupertino-, CA 95014
PERMIT CANNOT BE FINALED AND COMPLETED UNTIL THIS CERTIFICATE
HAS BEEN M= AND RETURNER To THE BUILDING DIVISION
Please refer to the attached California Civil Code Sections 1101.1 — 1101.8 which are part of this Certification form.
1. Is your real property a registered -historical site?
El Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Sign below and skip the rest of the,form.
Owner' Signature: 0 Signed by: Date: 1/5/2017
E� No Go to Question 2.UL&
E EC5F6418,.;
2. Does your real property have a licensed plumber certifying that, due to the age or configuration of the property or its
plumbing, installation of water -conserving plumbing fixtures is not technically feasible?
Cl Yes Civil Code Sections 1101.1 through 1101.8 do not apply. I - t,
0 The licensed plumber's certification has been provided to the Building Division,
Sign below and skip the rest of the form.
Do uS' db:
Owner' Signature: Date. -1/5/2017,
E)�q
No Go to Question 3.
6F94C9EEC5F6419_
3. Is water service permanently disconnected for your building?
0 Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Sign below and skip the rest of the form.
Owner' Signature: D S-10 d b Date: 1/5/2017
3 NT o Go to Question 4.
E
4. Is your real property built and available for use or occupancy on or before January 1, 1994?
21 No My real property is built and available for use or occupancy After January 1, 1994.
Civil Code Sections 1101.1 through 1101.8 donot apply. Sign below and skip the rest of the form.
e—DoCuSIdnedby:
Owner' Signature. Y40y1' UTA, Date: 1/5/2017
E1_ Yes My real property i§-beilk m&a&aRpble for use or occupancy on or before January 1, 1994.
Civil Code Sections 1101.1 through 1101.8 apply. Refer to the attached.
El My property is a single family residential real property. See Civil Code Section 1101.4.
On and after January 1, 2014, building alterations or improvements shall require all non-compliant plumbing
fixtures to be replaced with water -conserving plumbing fixtures throughout the building. -On or before, January 1,
2017, all non-compliant plumbing fixtures shall be replaced with water -conserving plumbing fixtures (regardless
of whether property undergoes alterations or improvements).
My property is aniultifanzily residential real property. See Civil Code Section 1101.5.
On and after January 1, 2014, specified building alterations or improvements shall require non- compliant
plumbing fixtures to be replaced with water -conserving plumbing fixtures.
On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water=
conserving plumbing, fixtures throughout the building (regardless of whether property undergoes alterations or
improvements).
My property is a commercial real property. See Civil Code Section 1101.5.
On and after January 1, 2014, specified building alterations or improvements shall require non-- compliant
plumbing fixtures to be replaced with water -conserving plumbing fixtures.
SB407 2015.doc revised 02104115