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B-2017-0911CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0911 20378 GILLICK WAY CUPERTINO, CA 95014-4413 (369 36 008) WILLOW GLEN ELECTRIC INC SAN JOSE, CA 95155 OWNER'S NAME: SANTHEBENNUR ARUN AND RAGHAVENDRAARCHANA OWNER'S PHONE: 214-213-0200 LICENSED CONTRACTOR'S DECLARATION License Class Q- Q 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. 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 ill comply with all non -point source regulat=rtheertino Mu ' ' al Code, Section 9.18. Signature Date 06-08-2017 OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1. I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) 2. I, as owner of the property, am exclusively contracting with licensed contractors to construct the project(Scc.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. 3. 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 06-08-2017 DATE ISSUED: 06/08/2017 PHONE NO: (408) 289-9725 BUILDING PERMIT INFO: X BLDG X ELECT —PLUMB _ MECH X RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: (I) EV CHARGING STATION (50 AMP)LOCATED IN GARAGE; PANEL UPGRADE (200 AMP) SAME LOCATION Sq. Ft Floor Area: I Valuation: $4990.00 APN Number: Occupancy Type: 369 36 008 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: 06/08/2017 RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant: Date: 06-08-2017 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 Municipal Code, Chapter 9.12 and the Health & Safety Code ctions 25505, 25533, d25 3, Owner or authorized agent: Date: 06-08-2017 CONSTRUCTION LENDING 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 CUPERTINO ALTERNATIVE ENERGY PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 • h+Itli1�la>e rilti� .��rlj, J, by _-3- �a 7, fW 313a ✓� w 71, -7. 3c> 3 0_4 PROJECT ADDRESS ?0 3 (j I - / / !, / Ay APN 1i 3' � 9 r SG -00? PH �1 (- 1 Y c� E-MAIL OWNER NAME -- � . ! n L ajLW STREET ADDF © /j /v C.ITY,tpTATn/Z�IP oG-I ( e? VlJ FAX .cA 141 pE�eLA CONTACT NAME Mark Londre PHONE (408)289-9725 E-MAIL office@willow lenelectric.com STREET ADDRESS n. O. Box 8430 CITY, STATE, ZIP San Jose, CA 95155 FAX(408)289-9725 11 OWNER 11OWNER-BUILDER❑ OWNER AGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME Mark Londre LICENSENUMBER 591918 LICENSETYPE ^-10 1 BUS. LIC N 15897 COMPANY NAME Willow Glen Electric, Inc. E-MAIL office@willowglenelectric.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 # 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 ElYes C3 No PROJECT IN FLOOD ZONE [3Yes E]No Eli SOLAR PANELS ELECTRIC VEHICLE CHARGING STA'T'ION 1 ❑ SOLAR WATER HEATING ❑ OTHER: _ FOR SOLAR PANELS: NUMBER OF PANELS/UNITS: KILOWATTS (COMMERCIAL ONLY): TOTAL VALUATION 14 Qq 0 •� '7 / DESCRIPTION OF WORK Electric Vehicle Charging Circuit: rU "),S0 adv V a00AILc AWc-Z- u)04940t�_- /A) 0C >-� ©A -b 10 P -7VA-A5e_P �>Wb (0 -2,qaV .5-0>44tp , L=rbl ( 4� k ewer - LO AJG7� /t/ SCS IV_ /,k/5/b4_:- 041z C 76�.3. RE D By my signature below, I certify to each of the following: 1 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 ru Iz s ves of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY W a ❑ OVER-TH&COUNTER ❑ EXPRESS ❑ STANDARD ❑ LARGE ❑ MAJOR AYApp_2011.doc revised 03116111 V-1