B-2018-0515 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0515
11901 PLACER SPRING CT CUPERTINO,CA 95014-5103(366 55 012) WILLOW GLEN
ELECTRIC INC
SAN JOSE,CA 95155
OWNER'SNAME: DATE ISSUED:03/28/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-10 Lic.#59 91
Contractor WILLOW GLEN ELECTRIC INC Date 04/30/2020 X BLDG X ELECT_PLUMB
I herebyform that I am licensed under the provisions of Chapter 9 —MECH X RESIDENTIAL_COMMERCIAL
a p p (commencing
with Section 7000)of Division 3 of the Business&Professions Code and that my
I[cense is in full force and effect. JOB DESCRIPTION:
(N)EV CHARGING STATION(50 AMP);(N)SUBPANEL(50 AMP);
I hereby affirm under penalty of perjury one of the following two declarations:
h. I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided to'
by Section 3700 of[he Labor Code,for the
�crformance of the work for which this permit is issued.
is issued. Sq.Ft Floor Area: Valuation$3230.00
APPLICANT CERTIFICATION
I certify that I have read this application and stale that the above
information Is correct.1 agree to comply with all city and county ordinances APN Number: Occupancy Type:
and stale laws relating to building construction,and hereby authorize 366 55 012
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 WORI{IS NOT STARTED
may accrue against said Clt n nsequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant lands and will comply with all non-point
source regulations pert etino and
Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature _ Date 0 312 8/2 0 1 8 Issued by:Jasmine Archbold
Dare:03/28/2018
TI
I hereby at'firm the I an,exempt from the Contractor's License Law t'or one of the RE-ROOFS:
following two reasons: All ..is shall be inspected prior to any roofing material being installed.If a roof is
t. 1,as owner o£the property,or my employees with wages as 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(See.7044,Business&Professions Code)
2. I,as .of the property,am exclusively contracting with licensed Signature ofAppli.md:
contractors to construct the project(See.7044,Business&Professions Code). Date:03/28/2018
1 hereby affirm under penalty of perjury one of the t'ollowing three declarations: ALL ROOF COVERINGS TO BE CLASS^'A"OR BETTER
t. I have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of One Labor Code,for the
performance of the 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 rend the hazardous materials requirements under Chapter 6.95 of the
Section 3700 ofthe 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
a. 1certify that in the performance of the work for which this permit is issued,l Health&Safety Cade,Section 25532(+)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
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California.If,aRer making Ibis certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I became subject to the Worker's Compensation provisions of the the Health&Safety Cade, lrr
performance
relating to building construction,and hereby authorize representatives of this city of work's for which this perm issued(Sec.3097,Clv C.)
toenter 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 ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Data 03/2.8/2018
Professional