B-2017-1469 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1469
18710 NEWSOM AVE CUPERTINO,CA 95014-3855(375 30 006) NILSENE BUILDER
INC
CUPERTINO,CA 95014
OWNER'S NAME: LIANG QIBIN AND WEI LIU TRUSTEE DATE ISSUED:09/05/2017
OWNER'S PHONE:408-406-3284 PHONE NO:(408)993-1229
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class j3 Lic.#1019073
Contractor NILSENE BUILDER INC Date 10/31/2018 X BLDG X 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:
TEMP POWER POLE (100 AMP)
I hereby affirm under penalty of perjury one of the following two declarations:
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.
z. I have and will maintain Worker's Compensation Insurance,as provided for by
M)Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$600.00
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 30 006
representatives of this city to enter upon,the above mentioned property for
inspection purposes. (We)agree to seve'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 inconsequence 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 regulations per Cupgitino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.1,1
Signature V 1 Date 09/5/2017 Issued by:Kim Dunbar
Date:09/05/2017
OWNER-BUILDER D,C ARA. ON
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:09/5/2017
I hereby affirm under penaltyof:per jury 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. 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 942 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
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 C pe i o Municipal Code,Chapter 9.12 and
exemption,I become'subject to the Worker's Compensation provisions of the the Health&Safety Code .ec o.s .05,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent: .II A_
APPLICANT CERTIFICATION Date:09/5/2017
I certify that I have read this application and state that the above information is CO.S •UC PAW i G •G NCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a co 'uction 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 A.RCHITECT'S DECLARATION
Code,Section 9.18'. I understand my plans shall be used as public records.
Licensed
Signature Date 09/5/2017 Professional
CONSTRUCTION PERMIT APPLICATION
w\\\ / B
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
1p, 10300 TORRE AVENUE • CUPERTINO,CA 95014-3255
wyan, (408) 777-3228 • building@cupertino.org PEMIT#B-201 - /
CUPERTINO REV# DEF#
•
❑ NEW CONSTRUCTION ❑ADDITION ❑ALTERATION ❑T.I. M MEP ❑RE-ROOF ❑SWIMMING POOL/SPA
PROJECT ADDRESS 1 7\O /vn \--,se
r Ave APNk 3,� 0- 0 jl
4 ! p /Vl
OWNER NAME ^�I PHONE Ltad-�a 6` 1 2 EN E-MAIL�&1 ,'Iv ISO&y..�ee. CO
STREET ADDRESS � ZIP
S .N1 t CITY, f-\l n C
IR]CONTRACTOR NAME ❑OWNER-BUILDER COMPANY NAME • LICENSE NUMBER LICENSE TYPE
1410.67 /4'11 seo' 3v;\k( i 0 C \o\qb r3 - 8 •
STREET ADDRESS CITY, ZIP
2106o Ne,r"���e re X 216 Cu PPr-E;4t CA cR'aILI .
E-MAIL
iI!�q ' ,CICY I PHONE
itg, 4-415 BU D —/ ` 1- tv4 ( f(
SAnP.t�C � c
❑ARCHITECT 0 OWNER ❑OWNER AGENT RI CONTRACTOR AGENT 0 ENGINEER❑DEVELOPER 0 TENANT
CONTACT NAME E-MAIL
Mai - Al; 5etn r i n a a ,\.ce'm • ..
STREET ADDRESS ' ' CITY;STATE,ZIP PHONE
S a n-.P
DECRIPTON
•
e ms1 e y-6 1(/ E tock cl C ,
❑SINGLE-FAMILY/DUPLEX ❑MULTIFAMILY 0 INDUSTRIAL 0 COMMERCIAL I
' EXISTING USE EXISTING SF NEW FLOOR SFI PORCH SF DECKSF DEMO SF STORIES# TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION($)
REMODEL - . REMODEL KITCHEN REMODEL OTHR GARAGE 0 ATTACHED •
BATHROOM SF SF SF SF 0 DETACHED
EXISING ❑YES EIGHLER 0 YES SECOND STORY ADDITION DYES'
FIRE SPRINKLERS 0 NO ' 0 NO. 0 NO ,
DWELLING SECOND DWELLING ❑YES'❑,ATTACHED❑DETACHED OTHER
UNITS# UNIT ADDITON: 0 NO S F
POOLS' ❑'FIBERGLASS 0 VINYL-LINED 0 GUNITE ❑PREFABRICATED , I
POOL-SF SPA-SF ' SPA ATTACHED ❑YES ®NO TOTAL-SF
RECE % :Y / TOTAL VALUATION:
• -Commercial or Multi-Family Buildings with Public Swiminine Pools requires Department of Environmental Heath approval / goo
RE-RO OFI EXISTING ROOF TYPE: ❑BUILT-UP ROOF❑ASPHALT SHINGLES❑WOOD SHAKES❑WOOD SHINGLES❑TILE OTHER(SPECIFY)
REMOVE/REPLACE❑NO IF NO PLYWOOD I=1 1/2" ❑3/8" PLYWOOD TYPE: PITCH: ROOF CLASS
El yes #OF LAYERS THICKNESS❑5/8" OTHER ❑OSB ❑CDX OTHER •12 A
PROPOSED ROOF TYPE:❑BUILT-UP ROOF,DASPHALT SHINGLES 0 WOOD SHAKES OWOOD SHINGLES ❑OTHER
*Provide a signed copy of the Cupertino's Tear-Off Policy SF #of SQUARES
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 provided is correct. I have read the Description of Work and verify it is accurate. I agree
to comply with all applicable local ordinances and stat laws relating to building construction. I authorize representatives of Cupertino to
enter the above-identified property,for inspection puYpo e . acknowledge and authorize all information contained on this application form
to be made available for public record. ,
Signature of Applicant/Agent: ! / Date:
SUPPLEMENTAL INFORMATION REQUIRED I`/ •,
*New SFD/Second Dwelling Units/Multifamily Dwellings:A Demolition permit is required prior to issuance of a building permit for all new construction:
*Commercial Buildings: Provide a completed Hazardous Materials Disclosure form.if any Hazardous Materials are being used as part of this project.
*Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application.
*HOA-Provide a letter of approval from the Home Owner's Association
BldgApp_2017.doc revised 08/01/17
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