B-2018-1250 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:3-2018-1250
10680 JOHNSON AVE CUPERTINO,CA 95014-3876(375 31 Ola) WILLOW GLEN
ELECTRIC INC
SAN JOSE,CA 95155
OWNER'S NAME: DA'Z'E ISSUED:07/26/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class CIO Llc.#591918
Contractor WILLOW GLEN ELECTRIC INC Date 0413012020 X BLDG—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:
NEW EV CHARGING STATION(GARAGE)(SO AMP)
I hereby affirm under penalty of perjury one of the following two declarations:
a. I have and will maintain a certificate of consent to self-insure for Workor's
Compeusation,as provided for by Section 3700 of the Labor Code,for the
performance ofthe work for which this permit is issued,
have read this applicallon 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 31 013
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 per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature % Date 7-26-2018 Issued by:Kim Dunbar
Date:07/26/2018
OWNER-
I hereby affirm that Tom exempt from the Conurector's License Law for one of the RF-ROOFS:
following I reasons: All roofs shall be inspected prior to any roofing material being installed.He roof is
r. 1,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree wren....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)
z. 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant.
contractors to construct the project(Sec.7044,Business&Professions Code). Date,7-26-2018
1 hereby afRrm trader penalty of perjury one of the following three doctor ath o o ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
n. I have slid will maintain a Certificate of Consent to self-iusure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance offhe work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
2. 1 have and will maintain Worker's Compensation Insurance,as provided for by I have read rhe hazardous materials requirements under Chapter 6.95 of fire
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534.1 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,J Health&Safety Code,Section 25532(u)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
Worker's Compensation pe laws of California,if,after become
this certificate of air contaminants as defined by Bre Boy Area Air Quality Management District I
P 8 will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions attic the 11.111,&Safety
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 MunicipalAftC1lITEC'1"S llF.CLAIIA'f10N
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date 7-26-2018 Professional