B-2018-1404 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1404
20683 SCOFIELD DR CUPERTINO,CA 95014-2945(3 59 09 012) WILLOW GLEN
ELECTRIC INC
SAN JOSE,CA 95155
OWNER'S NAME: DATE ISSUED:08/21/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION- BUILDING PERMIT INFO:
License Class CC=10 LIc.4591918
Contractor WILLOW GLEN ELECTRIC INC Date 04/30/2020 X BLDG_ELECT_PLUMB
1 hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH X RESIDENTIAL COMMERCIAL
with Secure 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(60 AMP)-GARAGE
I 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 faWorker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance ofdre work for which this permit is issued.
z. 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:$2240.00
APPLICANT CERTIFfCATION
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 359 09 012
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 theCupetino unicipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Data 8-21-2018 issued by;Kim Dunbar
Date:08/21/2018
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons; All ..Is shall be inspected on.,to any roofing material being installed.It a root'is
u I,as owner of tha property,.,my employees with wages as their sole Installed without first obtaining at,inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for mspeetion.
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). Data:8-21-2018
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS I'D BE CLASS"A"OR BETTER
r. 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 Cade,for the -
pc f.mireace of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
I, I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements carder Chapter 6.95 of the
Section 3700 of the Labor Code,fur the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534.I 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,I Health&Safety Code,Section 25532(a)should I store or handle hazardous
shall not em In �n on in my manner so as to become subject to the material.Additionally,should I use equipment or devices which emit hazardous
p y. y person y 1 air eont nal...U ns defined by the Bay Arca At,Quality Management District I
Worker's Compensation laws of Colifernia.If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 255 ,255J,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall /
be deemed revoked. Owner or authorized agbnt:
APPLICANT CERTIFICATION Date:8-21-2018
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 AIiCHl'CEC1"S DECLAl2A'1'ION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date 8-21-2018
Professional