B-2017-0838CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-0838
10108 JUDYAVE CUPERTINO, CA 95014-3523 (375 11 009)
WILLOW GLEN
ELECTRIC INC
SAN JOSE, CA 95155
OWNER'S NAME: LI RICHARD C AND INGRID S TRUSTEE & ET AL
DATE ISSUED: 05/25/2017
OWNER'S PHONE: 408-621-6448
PHONE NO: (408) 289-9725
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class C -JL 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:
(N) EV CHARGING STATION (50 AMP); (I) EV CHARGING STATION
I hereby affirm under penalty of perjury one of the following two declarations:
(30 AMPS) - GARAGE
t. 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
Sq. Ft Floor Area:
Valuation: $2840.00
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
APN Number:
Occupancy Type:
and state laws relating to building construction, and hereby authorize
375 11 009
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 regulatio per the C ertino nicipal ode, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 05-25-2017
Issued by: Kim Dunbar
OWNER -BUILDER DECLARATION
Date: 05/25/2017
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
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)
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: 05-25-2017
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
t. 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 snaking this certificate of
will maintain compliance with the Cupertino Municipal Code, Ch pter 9.12 and
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
the Health & Safety Code, Se ons 2550 25533, and 534.
be deemed revoked.
Owner or authorized agent:
APPLICANT CERTIFICATION
Date: 05-25-2017
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 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.
Licensed
Signature Date 05-25-2017
Professional
0
ALTERNATIVE ENERGY PERMIT APPLICATION
its COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTINO I (408) 777-3228 • FAX (408) 777-3333 • L)_wLf io,or
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PROJECT ADDRESS M /fi t J j� �%
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OWNER NAME �/
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E-MAIL
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STREET ADDRESS,A� J -i ' \ I
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CITY, STATEs, ZIP
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FAX
CONTACT NAME Mark Londre
PTIONE (408)289-9725
E-MAIL
office@willowglenelectric.com
STREET ADDRESS R O. Box 8430
CITY, STATE, ZIP San Jose, CA 95155
FAX (408)289-9725
1
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT 11CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITF,CT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME Mark Londre
LICENSE NUMBER 591918
LICFNSETYPE ^-10
1
BUS. LIC N 15897
COMPANY NAME Willow Glen Electric, Inc.
E-MAIL office@willowglenelectric.com
FAX (408)289-9725
STREET ADDRESS p 0. Box 8430
CITY, STATE, ZIP San Jose, CA 95155
PHONE (408)289-9725
ARCHITECT/ENGINEER NAME N/A
LICENSE NUMBER
BUS. LIC p
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF SFD or Duplex ❑ Multi -Family
STRUCTURE: ❑ Commercial
PROJECT IN WILDLAND
URBAN INTERFACE AREA ❑ Yes El No
PROJECT IN
FLOOD ZONE [3Yes [3No
❑ SOLAR PANELS
I ialELECTRIC VEHICLE CHARGING STATION
1 ❑ SOLAR WATER HEATING
❑ OTHER: _
FOR SOLAR PANELS. NUMBER OF PANELS/UNITS:
KILOWATTS (COMMERCIAL ONLY):
TOTAL VALUATION
DESCRIPTION OF WORK
Electric Vehicle Charning Circuit: )A f2N tS ` f tJ sTA -40V
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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 const ln .z epres ves of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: J 1 lx Date:
SUPPLEMENTAL INFORMATION REQUIRED
OFFICE USE ONLY
W
a
❑ OVER-THE-COUNTER
❑ EXPRESS
❑ STANDARD
❑ LARGE
❑ MAJOR
PVApp_2011.doc revised 03116/11
DocuSign Envelope ID: 939F8FE9-0165-41 E8 -8950-9A1 DB6F7546E
CUPERTINO
SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildingecupertino.org
r1
-1 -17 Tjf
Permit No.B-2017-0838
Address 10108 Judy Avenue # of Alarms Smoke: 9 Carbon Monoxide: 3
PERMIT CANNOT BE FINALED AND COMPLETED UNTIL THIS CERTIFICATE
HAS BEEN SIGNED AND RETUNED TO THE BUILDING DIVISION
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 R314 and CBC 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 ALARM
CO ALARM
Outside of each separate sleeping area in the immediate vicinity of the
bedroom(s)
X
X
On every level of a dwelling unit including basements
X
X
Within each sleeping room
X
Carbon Monoxide alarms 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 R314 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 alarm(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.
1 have read and agree to comply with the terms and conditions of this statement
Owner (or Owner Agent's) Name:�1(.IAYQ1,.
D/ocusign/Ied by:
Richard Li
Si .
natur ....................................... .... Dat5/..31�20
Contractor Name:
21e227can316486...
Signature...-..-...-.-. . ...... . .. . . ............. -...Lic.#...................................... Date: ...................
Smoke and CO formxloc revised 03118114
.7
DocuSign Envelope ID: 939F8FE9-0165-41 E8 -8950-9A1 DB6F7546E
CUPERTINO
WATER -CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 - buildinQ(&cupertino.org
Owner Name Richard Li Permit No. B-2017-0838
Address 10108 Judy Avenue, Cupertino, CA 95014
PERMIT CANNOT BE FINALED AND COMPLETED UNTIL THIS CERTIFICATE
HAS BEEN SIGNED AND RETURNED 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'?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Sign below and skip the rest of the form.
Doeusigned
Owner' Signature: by; Date: 5/31/2017
Cit No Go to Question 2.E� b
218227C9A316486...
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?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply.
❑ The licensed plumber's certification has been provided to the Building Division.
Sign below and skip the rest of the form.
DocuSigned
Owner' Signature: by:
U by;
i`Date: 5/31/2017
Li No Go to Question 3. t
218227C9A316486...
3. Is water service permanently disconnected for your building?
❑ Yes Civil Code Sections 1101.1 through 1 101.8 do not apply. Sign below and skip the rest of the form.
Owner' Signature: by; Date: 5/31/2017
13 No Go to Question 4.E(%,gyd U
218227C9A316486...
4. Is your real property built and available for use or occupancy on or before January 1, 1994?
® No My real property is built and available for use or occupancy after January 1, 1994.
Civil Code Sections 1101.1 through 1101.8 do not apply. Sign below and skip the rest of the form.
DocuSigned by:
Owner' Signature: K&a4 U Date: 5/31/2017
❑ Yes My real property iitvndaysibble for use or occupancy on or before January 1, 1994.
Civil Code Sections 1101.1 through 1101.8 apply. Refer to the attached.
Cl 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 a meltifamil' 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. Sec 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