B-2018-1251 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR, PERMIT NO:B-2018-1251
11061 S STELLING RD CUPERTINO,CA 95014-5022(362 18 053) WILLOW GLEN
ELECTRIC INC
SAN JOSE,CA 95155
OWNER'S NAME: DATE ISSUED:07/26/2018
- OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C10 Lic.#591918
Contractor WILLOW GLEN ELECTRIC INC Date 04/30/2020 X BLDG X ELECT—PLUMB
I hereby affirm that I am licensed ander the provisions of Chapter 9(commencing —MECH X RESIDENTIAL—COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license 1s In full force and effect. - JOB DESCRIPTION:
NEW EV CHARGING STATION-GARAGE(30 AMP);NEW SUB-
1 barony affirm under penalty of perjury one of the following two declarations: PANEL(50 AMP)
t. 1 have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided far by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
,
Section 3700 of the Labor Code,for the performance of the work fm which this
permit is issued. Sq.Ft Floor Area: Valuation:$1780.00
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 362 18 053
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 unders nds and will comply with all non-point
source
"" /�le 7-26-2018 Issued by:Kim Dunbar
Date:07/26/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS
following two reasons: All roofs shall be inspected prior to any roofing material being installed,Ifo roofis -
n. 1,as owner of 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 1'or, inspection.
sale(Sec.7044,Business&Professions Code)
2. 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant
contractors to construct the project(Sec.7044,Business&Professions Code). Date: -26-2048
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TORE CLASS"A"OR BETTERr. 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
x. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the lu—ndous mW erhtls requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the perfom auee of lire uvodc 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
s. I certify that in the perfornamee of the work for which this permit is issued,I Realth&Solely Code,Section 25532(a)should 1 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
ahcontaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California.If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
emption,I become subject to the Worker's Compensation provisions critic the Health&Safety Code,Sections 2550 y$55331 yttTd34.
Labor Cade,I must forthwith comply with such provisions or this permit shall
Owner
be deemed revoked.
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 bullding construction,and hereby authorize representatives of this city Of work's for which this permit is Issued(Sec,3097,ON 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 ARClll'1'EC'1"S UECLARATION
Code,Section 9.18. I understand my plans shall be used as public records.
SignatureLicensed
Date 7-26-2018
Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2018-1251
11061 S STELLING RD CUPERTINO, CA 95014-5022 (362 18 053) WILLOW GLEN
ELECTRIC INC
SAN JOSE, CA 95155
OWNER'S NAME: DATE ISSUED: 07/26/2018
OWNER'S PHONE: PHONE NO: (408) 289-9725
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-10 Lic. #591918
Contractor WILLOW GLEN ELECTRIC INC Date 04/30/2020. X BLDG X 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 the Business & Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
I hereby affirm under penalty of perjury one of the following two declarations: NEW EV CHARGING STATION - GARAGE (30 AMP); NEW SUB-
PANEL (50 AMP)
1. I have and will maintain a certificate of consent to self-insure for Worker's REV #1 - CHANGE PLAN FOR SUBPANEL (50 AMP) - ISSUED
Compensation, as.provided for by Section 3700 of the Labor Code, for the 10/30/18
performance of the work for
p which this permit is issued.
2. 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: $1780.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
information is correct. l agree to comply with all city and county ordinances APN Number: Occupancy Type:
and state laws relating to building construction, and hereby authorize 362 18 053
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 STAR
may accrue against said City in consequence of the granting of this permit. . TED
Additionally, the applicant understands and will comply with all non-point WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cupertino MDI icipal Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 10/30/18 Issued by: Kim Dunbar
Date: 07/26/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed. If a roof is
1. I, as owner of 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 (Sec.7044, Business & Professions Code)
2. I, as owner of the property, am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project (Sec.7044, Business & Professions Code). Date: 10/30/18
I hereby affirm under penalty of perjury one of the following three declarations:
1. I have and will maintain a Certificate of Consent to self-insure for Worker's ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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
2. I have and will maintain Worker's Compensation Insurance, as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code, for 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
' material. Additionally, should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If, after making this certificate of will maintain compliance with th"dand
Municipalde Chapter exemption, I become subject to the Worker's Compensation provisions of the p 9.12 and
p p the Health & Safety C . 25534.
Labor Code, I must forthwith comply with such provisions or this permit shallbe deemed revoked. Owner or authorized agent: — ,
APPLICANT CERTIFICATION Date: 0 30/ 8 ``
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 ARCHITECT'S DECLARATION
Code, Section 9.18. 1 understand my plans shall be used as public records.
Signature Date -1-0/30/18 Licensed
Professional