B-2018-0862 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:3-2018-0862
19120 MEIGGS LN CUPERTINO,CA 95014-3562(375 35 046) VOLTZ ELECTRIC
SAN JOSE,CA 95123
OWNER'S NAME: DATE ISSUED:05/18/2018
OWNER'S PHONE: PHONE NO:(408)464-8588
LICENSED CONTRACTOR'S I BUILDING PERMIT INFO:
License Class ELECTRICAL Lic.#912372
Contractor VOLTZ ELECTRIC Date 07/31/2018 X BLDG X 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:
PANEL UPGRADE(200 AMP)SAME LOCATION
1 hereby affirm under penalty of perjury one of the following two declarations:
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 not is issued.
z, I have and will maintain Worker's Compensation Insurance,as in 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:$4800.00
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 35 046
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 regulations pe tthh Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature ¢' Data 05-15-2018 Issued by:Kim Dunbar
Date:05/18/2018
OWNER-BUILDER DEC],flIXI]ON
I hereby affirm that I am exempt from the Contractor's License Law for one of the BE-ROOFS:
following he o reasons; All root's 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[he wore,and the structure is not intended or offered Por inspertion.
sale(Sec.7044,Business&Professions Code)
z. 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant:_
contractors to construct the project(Sec.7044,Business&Professions Coda), Date:05-15-2018
1 hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER1. 1 have and will maintain a Certificate of Consent to self-insure Po'Worker's
Compensation,as provided for by Section 3700 of the Labor Cade,for the
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. I have and will maintain Worker's Compensation Insurance,as provided far by I have read the hazardous materiels requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of tic work for which this California Healon&Safety Code,Sections 25505,25533,and 25534.1 will
permit is issued. nnIntnin compliance with the Cupofine Municipal Code,Chapter 9,12 and the
a. I certify that in the performance of the work for which this permit is issued,l r Health&Safety Code,Section 25532(a)should I store or handle lmzardous
shell not employ any person in any manner so as to become subject to the materinl.Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Buy Arca 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,1 became 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:
APPLICANT CEIITI IrICATION Date:05-15-2018
I certify that I have read this application and state that the above information is CONSTRUCTION LGNDI\ AGENCY
correct.I agree to comply with all city and county ordinances and slate 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 All-C I T'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
SignatureLicensed
Date 05-15-2018
Professional