B-2018-1168 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1168
10140 BY RNE AVE CUPERTINO,CA 95014-2808(35716163) OWNER/BUILDER
OWNER'S NAME:WANG YU-JEN DATE ISSUED:07/11/2018
OWNER'S PHONE: PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.4
Contractor OWNER/BUILDER Dale X BLDG_ELECT_PLUMB
I hereby Me,.that I nm licensed under the provisions f Cha ter 9(commencing —MECH X RESIDENTIAL COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in fail force and effect. JOB DESCRIPTION:
INSTALL(N)TESLA CAR CHARGER IN GARAGE(60 AMPS)
1 hereby affirm under penalty of perjury one of the fallowing two declarations:
r. I have and will maintain acertificate 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.
x. 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. Sq.Ft Floor Area; Valuation;$1500.00
APPLICANT CER'ftFICATION
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 357 16 163
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 WORI{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 per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Data 7111/2018 Issued by:Haley McKee
Date:07/1(/2018
OWNER-BUILDER DECLARATION
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
/
compensation,will do the work,and the snvchue is not intended or offered for inspection.
sale(Sec.7044,Business&Prot'essmns Code)
z, I,as owner of the property,am exclusively contracting with licensed Signature of ApplicanC
contractors to construct the project(See.7044,Business&Professions Code), Date:7/11/2018
1 hereby irfifirtnumber penalty of perjury one fthe following.three declarations:
I. I have and will maintain a Certificate-of Consent to self-insure for Worker's ALI,ROOPCOVEIHNGSTO BE CLASS"A"OR BETTER
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,Suctions 25505,25533,and 25534.1 will
Permitmaintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
is issued. Health&Safety Code,Section 25532(a)should t store or handle hazardous
I certify that in the performance of the work fm'which this permit is issued,I material.Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the air contaminants ns dented by the Bay Area Air Qualfty 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,l become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections r5O5,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this perndt shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Dat-7/1112018
I certify that I.have read this application and state that the above Information is EQNSTRUC9'I L' DING AGEN V
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a constructi 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 properly 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 ARCIIITECT'S DECLARATION
Code,Section 9,18, I understand my plans shall be used as public records.
Signature DateZL11L,
8 Licensed
Professional