B-2017-0196CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-0196
10561 WUNDERLICH DR CUPERTINO, CA 95014-3660 (375 33 052)
NILSENE BUILDER
INC
CUPERTINO, CA 95014
OWNER'S NAME:
DATE ISSUED: 08/07/2017
OWNER'S PHONE: 9615PHONE
NO: (408) 993-1229
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class GENERAL BUILDING CONTRACTOR Lic. #1019073
Contractor NILSENE BUILDER INC Date 10/31/2018
X BLDG _ELECT _PLUMB
—
X RESIDENTIAL COMMERCIAL
I hereby affirmMECH
that I am licensed under the provisions of Chapter 9 (commencing
— — —
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
(1) 2 STORY SFD (2,248 S.F); ATTACHED GARAGE (426 S.F); PORCH
I hereby affirm under penalty of perjury one of the following,two declarations:
(341 S.F).
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 Code, for the
erformance of the work for which this permit is issued.
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
Sq. Ft Floor Area: 2248
Valuation: $550000.00
permit is issued:
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
375 33 052
375
R-3 (Custom),R-3 (Custom),U (Private Gar Ag Bldg),U
representatives of this city to enter upon the above mentioned property for
(Private Gar /Ag Bldg)
inspection purposes. (We) agree to save indemnify and keep harmless the
City of Cupertino against liabilities, judgments, 'costs, and expenses which
may accrue against said City in consequence of the granting of this permit.
PERMIT EXPIRES IF WORK IS NOT STARTED
Additionally, the applicant understands and will comply with all non-point
WITHIN 180 DAYS OF PERMIT ISSUANCE' OR
source regulation�.er� e Cpertino Municipal Code, Section 9.18.180
DAYS FROM LAST CALLED INSPECTION.
Date 8/7/2017
Issued by: Jasmine Archbold
Date: 08/07/2017
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
RE-ROOFS:
1. I, as owner of the property, or my employees with wages as their sole
All roofs shall be inspected prior to any roofing material being installed. If a roof is
compensation, will do the work, and the structure is not intended or offered for
installed without first obtaining an inspection, I agree to remove all new materials for
sale (Sec:7044, Business & Professions Code)
inspection.
2. " Las owner of the propert}; am exclusively contracting with licensed
contractors to construct the project (Sec.7044, Business & Professions Code).
Signature ofApplicant:
Date: 8/7/2017
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.
2. I have and will maintain Worker's Compensation Insurance, as provided for by
HAZARDOUS MATERIALS DISCLOSURE
Section 3700 of the Labor Code, for the performance of the work for which this
I have read the hazardous materials requirements under Chapter 6.95 of the
permit is issued.
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
3. 1 certify that in the performance of the work for which this permit is issued, I
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
shall not employ anyperson in any manner so as to become subject to the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
Worker's Compensation laws of California. If, after making this certificate of
air contaminants as defined by the Bay Area Air Quality Management District I
exemption, I become subject to the Worker's Compensation provisions of the
will maintain compliancewith th C rtino Municipal Code, Chapter 9.12 and
Labor Code, I must forthwith comply with such provisions or this permit shall
the Health & Safety Co e, o s 25505, 25533, and 25534.
be deemed revoked.
APPLICANT CERTIFICATION
Owner or authorized ag xt
I certify that I have read this application and state that the above information is
Date: 8/71201
correct. I agree to comply with,all city and county ordinances and state laws.
relating to building construction,,and hereby authorize representatives of this city
TR LENDING AGENCY
I hereby affirm that there is a ch truction lending agency for the performance
to enter upon the above mentioned property for inspection purposes. (We) agree
of work's for which this permit is issued (Sec. 3097, Civ C.)
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Name
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands
Lender's Address
and will comply with all non-point source regulations per the Cupertino Municipal
Code, Section 9.18.
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature Date 8n/2o17
Licensed
Professional