B-2017-1130 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1130
10810 WLJNDERLICH DR CUPERTINO,CA 95014-3851(375 22 014) NILSENE BUILDER
INC
21060 HOMESTEAD
RD 216 CUPERTINO,
CA 95014
OWNER'S NAME: DATE ISSUED:03/26/2019
OWNER'S PHONE: PHONE NO:408-499-6595
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#1019073
Contractor NILSENE BUILDER INC Date 10/31/2020 X BLDG —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:
(N)2 STORY SFD; IST FLOOR(1302 SQ FT);ATTACHED GARAGE
I hereby affirm under penalty of perjury one of the following two declarations: (430.72 SQ FT);FRONT COVERED PORCH(71 SQ FT)AND REAR
1. I have and will maintain a certificate of consent to self-insure for Worker's PORCH(200 SQ FT);2ND FLOOR(1102 SQ FT)WITH(3)BALCONIES
Compensation,as provided for by Section 3700 of the Labor Code,for the (260 SQ FT).
performance 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:2404 Valuation:$600000.00
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 75 Number: Occupancy Type:
3
and state laws relating to building construction,and hereby authorize 375 22 014 R-3(Custom)
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 understands and will comply with all non-point
source regulations Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 3/26/19 Issued by:Haley McKee
Date:03/26/2019
OWNER-BUILDER DE LARATION
V
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:3/26/19
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. 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
and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:3/26/19
I certify that I have read this application and state that the above information is CONSTRU&ION 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. I understand my plans shall be used as public records.
Licensed
Signature Date 3/26/19
BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS:
OWNER'S NAME: Not provided
OWNER'S PHONE: Not Provided
CONTRACTOR:
NILSENE BUILDER INC, 21060 HOMESTEAD ROAD #216 CUPERTINO
CONTRACTOR PHONE:
4084996595
DATE ISSUED 10/30/2019 9:59:35 AM
ISSUED BY: KDUNBAR
VALUATION: $600000
JOB DESCRIPTION
FT); ATTACHED GARAGE (430.72 SQ FT); FRONT COVERED PORCH (71 SQ FT) AND REAR PORCH (200 SQ FT); 2ND FLOOR (1102 SQ FT) WITH (3)
- FIRST FLOOR: INSTALL ELEC FIREPLACE LIVING RM AND REDUCE SIZE OF (2) WINDOWS; REDUCE SIZE OF (2) WINDOWS IN KITCHEN; RELOCATE
INCREASE MASTER BEDROOM BALCONY (10.5 SF) AND INCREASE PLATE HEIGHT AND INSTALL FLAT ROOF; INCREASE SIZE OF BALCONY NEXT TO
#1 - ROOF TRUSSES -ISSUED 10-30-2019
(N) 2 STORY SFD; 1ST FLOOR (1302 SQ
BALCONIES (260 SQ FT) REVISION #1
ELECTRICAL METER. SECOND FLOOR:
BEDRM #5 (30 SF). DEFERRED SUBMITTAL
LICENSED CONTRACTOR DECLARATION
9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full
CONTRACTOR:
NILSENE
LICENSED
B GENERAL
LICENSED
1019073
EXP
10/31/2020
I hereby
force
I hereby
BUILDER INC
CLASS:
BUILDING CONTRACTOR
NO:
DATE:
affirm that I am licensed under
and effect.
affirm under penatiy of perjury
I have and will maintain a certificate
for which this permit is issued.
I have and will maintain Worker's
I certify that in the performance
laws of California. If,
with such provisions or this
the provisions of Chapter
one of the following three
of consent to self -insure
Compensation Insurance, as
of the work for which this permit
after making this certificate of
permit shall be deemed revoked.
declarations:
for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the
work
provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
is issued, I shall not employ any person in any manner so as to become subject to the Worker's
exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith
V
issued.
Compensation
comply
HAZARDOUS MATERIALS DISCLOSURE
6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance
I have read the hazardous materials requirements under Chapter
the Cupertino Municipal Code, Chapter 9.12 and the Health
V
with
equipment
Municipal
& Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use
defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino
25505, 25533, and 25534.
this project.
Firm Certification No:
or devices which emit hazardous air contaminants as
Code, Chapter 9.12 and the Health & Safety Code, Sections
An EPA Lead -Safe Certified Renovator will be responsible for
Firm Name:
No EPA Lead -Safe Certified Firm is required for this project.
Certified
v
CONSTRUCTION LENDING AGENCY
lending agency for the performance of the work which this permit is issued (Section 3097, Civil Code).
Lender's Address:
I hereby
Yes
affirm
under penalty of perjury that there is a construction
No
V
Lender's
Name:
APPLICATION CERTIFICATION
and state that the above
: