B-2018-1050 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1050
18871 TILSON AVE CUPERTINO,CA 95014-3654(375 16 039) TESLA ENERGY
OPERATIONS,INC.
FREMONT,CA 94555
OWNER'SNAME: DATE ISSUED:06/21/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class CIO Lic.!1888104
Contractor TESLA ENERGY OPERATIONS,INC Date 12/31/2018 XBLDG—ELECT—PLUMB
I hereby affirm that I am licensed under the provisions at Chapter 9(commencing —MECH X RESIDENTIAL—COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in fall farce and effect. JOB DESCRIPTION:
(N)EV CHARGING STATION-(60 AMPS)
I hereby affirm under penalty of perJnry one of the following two declarations:
t. 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.
have and will maintain Worker's Compensation Insurance,as provided for by
Scotian 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$1000.00
APPIdCANT 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: Oceapancy Type:
and state laws relating to building construction,and hereby authorize 375 16 039 _
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 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 regulatioys per the Cupertino Municipal Cade,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
—�
Signature Data 06/21/2018 Issued by:Jasmine Archbold
Date:06/21/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I an,exempt from the Cmrtractor's License Law I'or one of the RE-ROOFS:
following two reasons: All roofs shall be inspected to to any roofing material being installed.If a roof is
r. 1,as owner oflhe 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 in offered far inspection,
sale(Scc.7044,Business&Professious Code)
z. I,as owner of the property,am exclusively contracting with licensed Signature ofApplicanC
contractors to construct the project(See.7044,Business&Professions Code), Date:06/21/2018
I hereby affirm under penalty ol'perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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
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 I have read the hazardous materials requh counts under'Chapter 6.95 of it,,
Section 3700 of the Labor Cade,for the performance of the work mi 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. 1 certify that in the performance of the work For which this permit is issued,l Health&Safety Cade,Section 25532(a)should 1 store or handle hozardous
shall not employ an n in an manner so as to become subject to the material.Additionally,should 1 use equipment or devices which emit hazardous
p y y person y ma J air contaminants as de uM by the Bay Area Air Quality Management District 1
Worker's Compensation laws of Catiforuie.If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,l become subject to the Worker's Conrpensetiou provisions of the the Health&
Labor Cade,I must forthwith comply with such to or this permit shall
m
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Data:06/21/2018
I certify that I have read this application and state that the above information Is CONSTRUC ON 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 MunicipalARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
icensed
Signature Data 06/2112018 L
Professional