B-2018-1310 CITY OF CUPERTINO BUILDING PERMIT
13UILDING ADDRESS: CONTRACTOR: PERMIT NO:3-2018-1310
18624 LOREE AVE CUPERTINO,CA 95014-3838(37525072) Nil,SENE BUILDER
INC
21060 I-IOMESTEAD
RD 216 CUPERTINO,
CA 95014
OWNER'S NAME: DATE ISSUED:08/02/2018
OWNER'S PHONE: PHONE NO:
LICENSED CONT'RACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class GENERAL BUILDING CONTRACTOR Lia#1012073 X BLDG X_ELECT PLUMB
Contractor NILSENE BUILDER INC Date 10/31/2018 — _
1 hereby affirm m
that 1 am licensed under the provisions of Chaplin 9(commencing —MECH X RESIDENTIAL—COMMERCIAL
with Section 7000)al'Division 3 of the Business&Professions Cade and that my
license is in till force and effect. JOB DESCRIPTION:
TEMP POWER POLE(100 AMPS)
I hereby affirm under penalty of perjury one of the following two declarations:
t. I have and will maintain a cartificnte of consent to self-unsure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
issued. Sq.Ft Floor Area: Valuation:$500.00
APPLICANT'CERTI FICA'f10N
I certify that I have read this applicatlon 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 25 072
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 faiditles,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 appli ant n,ed tends and will comply with all non-point
source regulations p the C el Municipal Code,section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Data 8-2-2018 Issued by:Kim Dunbar
Date:08/02/2018
E -BUILDS
1 hereby aflirm tlmt I am exempt from[hc 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
u 1,as owner of the in or my employees with wages as their sole installed without first obtaining an inspection,l agree to remove all new materials forcompensation,will do the work,and the stmemre is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
z, 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:8-2-2018
I hereby affirm under penalty of perjury one of the fallowing three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
r. I 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 ortha 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 requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work Cor 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 die performance of the work fmwhich this pemhit is issued,1 health&Safety Code,Section 25532(x)should I stare or handle hazardous
shall not employ any person in any.miner an 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 Qual(ty Management District I
Worker's Compensation laws of Califomia.If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,l became subject to the Worker's Compensation provisions of the the Health&Safety
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there Is a cons ruction 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 Ilabiftie%
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 8-2-2018 Licensed