D-2017-0058 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:D-2017-0058
10720 CULBERTSON DR CUPERTINO,CA 95014-3559(375 34 022) NILSENE BUILDER
INC
CUPERTINO,CA 95014
OWNER'S NAME: PANDHARIKAR ANAND M AND DESAI PURVI S DATE ISSUED:08/31/2017 •
OWNER'S PHONE:408-421-0781 PHONE NO:(408)993-1229
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class 13 Lic.#1019073
Contractor NILSENE BUILDER INC Date 10/31/2018 _BLDG _ELECT _PLUMB
MECH X RESIDENTIAL, COMMERCIAL
I hereby affirm 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:
DEMO- 1-STORY HOUSE(971 S.F.);DETACHED GARAGE(305 S.F.)
I hereby affirm under penalty of perjury one of the following two declarations:
i. 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.
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:$10000:00
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 375 34 022
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 applican,understands and will comply with all non-point
source regulations•-rthupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signa r ` r' � Date 8/31/2017 Issued by:Jasmine Archbold
V!V I Date:08/31/2017
. ►E'-: I IE' 1 L.RATII,
117
I hereby affirm t t 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
a. 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 stricture 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:8/31/2017
I hereby.affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. 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
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
2. SI 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. 1 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
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,after making this certificate of will maintain compliance with the Cu•err. o Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of thethe•Health&Safety Code,`l cti.1 s'5505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall µfir 1 f/
be deemed revoked. Own: authorized agent: / . I' 1 of
APPLICANT CERTIFICATION D td I ' V
I certify that I have read this application and state that the above information is I . R Cil► ESDI►
correct..1 agree to comply,withall city and county ordinances and state laws I hereby affirm that there is a consWction 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. I understand my plans shall be used as public records.
• Licensed
Signature__ _Date 8/31/2017 Professional •
\� / DEMOLITION PERMIT APPLICATION
' COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
4ST,,9s, 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333•buildinq(cilcupertino.orq
-2.c1-D OO
PROJECT ADDRESS 10 7 2 c C U \\De J 1 So 11 A je APN# �+f 1 5 — `3�-0
( -7.
OWNERNAME A el v
�Qartnrlc,lK.'`VPHONE HOct-Li21-C .�IEMAIL �bW'eCV+Per^11/IC'r0Q..A yo< ),c.WlSTREET ADDRESS \n ?„72 c C' \II0 I H n o v- CITY, STATE,ZIP^V pee'l o n a FAX O
CONTACT NAME lJ T'L l- l PHONE l: Y f E-MAIL
MCHC II ua.g.0 �iq4-65x5 yi1seAe�ncat\y'I�;I ,Qcwi
STREET ADDRESS 211ti 6 i \Id ol)p % L"0-14 Ca CITY,STATE,ZIPFAX
CU P er k', a
❑OWNER 0 OWNER-BUILDER 0 OWNER AGENT IP<ONTRACTOR 0 CONTRACTOR AGENT 0 ARCHITECT 0 ENGINEER 0 DEVELOPER 0 TENANT
CONTRACTOR NAME A p ^ C LICENSE NUMBER ka LICENSE_TYPE BUS.LIC#
COMPANYNAME n;` sey, �u A r 1 n C E-MAIL FAX 4d�.5L� 2,C{6'-i5
STREET ADDRESS 21 e 66, e WI r S fi e e-ck it d CITY,STATE,ZIP_U r I•n PHONE
DESCRIPTION OF WORKr
Dem �a q� 5ROI- eXi' )r;nb Innw,p
rki ein e A 0_0.. 6P
RESIDENTIAL #DWELLING OFFICE USE ONLY" w,. " ,
FLOOR AREA UNITS USE '" :OCC. ' "TYPE ,',;SQ.FT.' VALUATIONS'' z. "
COMMERCIAL
FLOOR AREA ° l
TYPE OF CONSTRUCTION #STORIES
AQMD JOB NUMBER EL�VED BY: • t - TOTAL VALUATION:
7#: 'J C813 C1 1i�.�. l0 act.0
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provi d i,correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buildin on:t;c'on. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: (f .1 0 Date: €_%\_‘
7
SUPPLEMENTAL INFORM ION ' QUIRED PRIOR TO ISSUANCE OF DEMOLITION PERMITOFFICE USE ONLY
Provide Job Number from Bay Area Air Quality Management District www.baaqmd.org @ 415-749-4762. PLAN CHECK TYPE:,
❑ EXPRESS
Provide three copies of a site plan showing protection for any trees 10"in diameter or more at 3'above grade.
CI STANDARD ' .',..--,.%:„f
./Isr/pvid�je letter from PG&E(408-725-3325)stating all gas and electric has been disconnected.
�ip $(31/Ii ❑ LARGE
VP PI nn ng Dept clearance to verify building is not considered an historical landmark.Allow 10 business days. I .+,
❑ MAJOR:
ovide letter of clearance of all vermin from a licensed pest control contractor.
lik3pl�icant shall call the Public Works Department at 408-777-3104 and schedule a"habitable dwelling"inspection. , k i',;: rt
Providelsigned Debris Bin and Recyclable Materials form.
Commercial Buildings Only: Provide Fire Dept clearance for fire suppression/alarm system review.
iii
DemoApp_2016.doc revised 03/29/16