B-2016-1181 Permit CardI CITY OF CUPERTINO BUILDING PERMIT
1059 WEST Hit I. Cr CUPERTINO, CA 95014-5063 (362 27 051)
NAME: HASEGAWA DAVE) KAND MONICA M TRUSTEE
PHONE:
y e a I sY Y l: N I t a I s
Icense class Lie. # 5q) q 1 5- C I O
ontractor ( WILLOW GLEN ELECTRIC INC) Date / ( [,
hereby affirm that I am licensed under the provisions of Chad/ter 9 (earn eacing
Ith Section 7000) of Division 3 of the Business & Professions Code and that my
tease Is in fell force and effect.
hereby affirm under penalty of perjury one of the following two declarations:
1. I have and will maintain a certificate of consent to self -insure for Worker's
WILLOW GLEN
'.LECfRIC INC )
AN POSE, CA 95155
PERMIT NO: B-2016-1181
DATE ISSUED: 01/I32016
PHONE NO:
PERMIT INFO:
BLDG X ELECT —PLUMB
MECH 7X RESIDENTIAL _ COMMERCIAL
DESCRIMON:
II (n) 125A sub -panel behind main panel, 50 amp-240 volt dedicated
It w/ a surface mounted NEMA 14-50 outlet. (Field verify required
;e floor space be maintained)
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
0 f 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: Veleatioa: $1790.00
APPLICANT CERTIFICATION
certify that I have read this application and state that the above
nformation is correct. I agree to comply with all city and county
ndinances and state laws relating to building construction, and hereby
authorize representatives of this city to enter upon the above mentioned
Foperty for inspection purposes. (We) agree to save Indemnify and keep
harmless the City of Cupertino against liabilities, judgments, costs, and
apenses which may accrue against said City in consequence of the
Iranting of this permit. Additionally, the applicant understands and will
:omply with all non -point source regulations per the Cupertino Municipal
;ode, Section 9.18.
signature S�I� L� Date
hereby affirm that I am exempt from the Contractor's License Law for one of the
i8owing two reasons:
1. I, m owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered
for sale (Sea7044, Business & Professions Code)
2. 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec.7044, Business & Professions Code).
hereby affirm under penalty of perjury one of the following three declarations:
1. 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
performance of the work for which this permit is issued.
2. 1 have and will maintain Worker's Compensation hnsmance, as provided for
by Section 3700 of the Labor Code, for the performance of the work for which
this permit is issued
3. I certify that in the performance of the work for which this permit is issued, I
shall not employ any pence in any manner so as to become subject to the
Worker's Compensation laws of California. If, after making this certificate of
exemption, I become subject to the Worker's Compensation provisions of the
Labor Code, I most forthwith comply with such provisions or this permit shall
be deemed revoked.
APPLICANT CERTIFICATION
certify that I have read this application and state that the above information is
orrect. I agree to comply with all city and county ordinances and state laws
slating to building construction, and hereby authorize representatives of this city
t enter upon the above mentioned property for inspection purposes. (We) agree
t save indemnify and keep harmless the City of Cupertino against liabilities,
idgments, costs, and expenses which may accrue against said City in
onsequence of the granting of this permit. Additionally, the applicant
nderstands and will comply with all non -point source regulations per the
�upertino Municipal Code, Section 9.18.
051
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
RE -ROOFS:
All roofs shag be inspected prior to any roofing material being installed. If a roof is
Installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
of Applicant:
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, S „ do a2 505, 25 aad 2 W.
Owner or uth zed agent:
Date: ►,i 3 ( G
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance
of work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed