B-2018-1383 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1383
10101 ORANGE AVE CUPERTINO,CA 95014-2828(35716147) HOMEOWNER
BUILDER
OWNER'SNAME: DATE ISSUED:08/15/2018
OWNER'S PHONE: PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lie.#
Contractor HOMEOWNER BUILDER Date 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 tho Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
(N)ELECTRIC VEHICLE CHARGING STATION(80 AMP) -(N)SUB-
I hereby affirm under penalty of perjury one of the following two declarations: PANEL(100 AMP)-GARAGE
r. 1 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
perfiamemao,of the work for which this permit is issued.
e. 1 have Rad 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 Flaor Area: Valuation:$1500.00
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 357 16 147
representatives of this city to enter upon the above mentioned properly 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 08/15/2015 Issued by:Jasmine Archbold
Date:08/15/2018
OWNER-BUIL DPR DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of the RE-ROOTS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
n. 1,as owner of the property,or my employees with wages us their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sce.7044,Busiret.&Professions Code)
z. I,as owner of the property,am exclusively contracting with licensed Signature ofApplicann
contractors to tonsovct the project(Sec.7044,Business&Professions Code), Date:09/15/2015
1 hereby affirm under penalty or perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I. I have and will maintain a Certifi
cate 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, HAZARDOUS MATERIALS DISCLOSURE
z. I have and will maintain Worker's Compensation Insurance,as provided for by t have read Hae hazardous materials requirements under Chapter 6.95 of the
Section 3700 o£the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,.,,it 25534.1 will
permit is issued maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
e
a. I certify that tune performance of[Inc work for which this permit is issued,] Health&Safety Code,Section 25532(x)should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the material.adnAdditionally,ideslmuld t use equipment or devices which emit hazardous
Worker's Compensation laws of California If,after naakin.this certificate of air a maintain
compliance
defined h the tinypeArea Air Quality Management District I
/� exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety and 25534.
Labor Code,I most forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:08/15/2015
1 certify that I have read this application and slate 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[hat 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 w' all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 1 understand my plans shall be used as public records.
Licensed
Signature Date 08/1512015 professional