B-2018-0793 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0793
21957 OAKLEAF CTCUPERTINO,CA 95014-lt37(326 18 066) WILLOW GLEN
ELECTRIC INC
EGORY BRENT AND VAN GELDER JULIE ATRUSTE D:05/09/2018
NE:408-705-1950 PHONE NO:(408)289-9725
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-10 Lic.#591918
Contractor WILLOW GLEN ELECTRIC INC Date 04/3012020 X BLDG_ELECT_PLUMB
I hereby nflirm tint f am licensed underthe 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 tall farce aid effect. JOB DESCRIPTION:
1 hereby affirm under penalty of perjury one of the following two declarations: (N)EV CHARGING STATION(60 AMPS)-GARAGE
h. l have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided Por by Section 3700 of the Labor Code,for the
performance ofthe work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,RS provided for by
yJJ\ Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Flaar Arca: Valuntion:$1840.00
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 326 18 066
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,casts,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply
e Date 05/09/2018 Issued by:Jasmine Archbold
Date:05/09/2018
ER-B I I MD'CLARATIO
I hereby affirm that I out exempt from the Contractor's License Law 1'ar one of tile RE-ROOFS,
fallowing two reasons: All roofs shall be inspected prior to any roofing material being installed.Its roof is
r. 1,as owner of the property,or my employees with wages as their sole installed without first obtaining on inspection,I agree to remove all new materials fur
ompensation,will do the work,and the structure is not intended or offered for inspection
sale(Sce.7044,Business&Professions Cade)
z. 1,as owner of the property,am exclusively contracting with licensed Signature ofApplicant
contractors to construct the project(Sce.7044,Business&Professions Code), Date:05/09/2018
1 hereby affirm under penalty of lurijury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
r. 1 have and will maintain a Certificate at'Consent to self ban a far%Volker's
Compensation,as provided for by Section 3700 a£the Labor Code,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 for by I have read the hazardous materials requirements Under Chapter 6.95 of the
Section 3700 of the Labor Code,for die performance of the work for which this California tienith&Safety Code,Sections 25505,25533,and 25534.1 will
permit is issued, m aintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
3. 1 certify that in the performance ofthe work for which this permit is issued,I tlmdth&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 t time equipment ar devices which emit hazardous
air contaminants us defined by the Bay Arco Air Quality Management District 1
Wo atlon laws of California.If,after nnaking this oertiYcate of will maintain compliance with the Cupertino Municipal Cade,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,SectioV255,25 and 25534.
Labor Cade,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent
APPLICANT CERTIFICATION Data:05/09/2018
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 ARCHIL I"S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
SignatureLicensed
Date 05!09!2018
Professional