B-2018-1285 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2018-1285
10801 GASCOIGNE DR CUPERTINO, CA 95014-3845 (375 31 027) NILSENE BUILDER
INC
21060 HOMESTEAD
RD 216 CUPERTINO,
CA 95014
OWNER'S NAME: DATE ISSUED: 11/02/2018
OWNER'S PHONE: PHONE NO: 408-499-6595
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic. # 0 90 3
Contractor NILSENE BUILDER INC Date 10/31/2020 X 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:
CONSTRUCT (N) SINGLE FAMILY DWELLING - ( 2197 SF); AND
I hereby affirm under penalty of perjury one of the following two declarations: ATTACHED 2-CAR GARAGE ( 427 SF)
. 1. I have and will maintain a certificate of consent to self-insure for Worker's REV#1-CHANGE FIXED WINDOW IN FRONT ROOM TO BAY
,,,,,.,,Compensation, as provided for by Section 3700 of the Labor Code, for the WINDOW, CHANGE FIXED WINDOW IN BACK ROOM, ROOF LINE,
performance of the work for which this permit is issued. OVERHANG AT BAY WINDOWS 6-INCHES -REMAINING HOUSE 10
have and will maintain Worker's Compensation Insurance, as provided for by INCHES - ISSUED 12/12/18
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. Sq. Ft Floor Area: 2197 Valuation: $500000.00
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 31 027 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
Additionally, the applica understands and will comply with all non-point PERMIT ISSUANCE OR
source regulations Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION,
Signature Date 12/12/18 Issued by: Kim Dunbar
Date: 11/02/2018
OWNER-BUILDER LARATION
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). Dater 12/12/18
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
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 Are Air Quality Management District I
Worker's Compensation laws of California. If, after making this certificate of will maintain compliance with the Cupertin Municipal Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the the Health & Safety Code, Sec 'o 25505, 25533, 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: 12/12/18
I certify that I have read this application and state that the above information is CONSTRUCTION L DING 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. 1 understand my plans shall be used as public records.
Signature Date 12/12/18 Licensed
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-201.8-1285
10801 GASCOIGNE DR CUPERTINO, CA 95014-3845 (375.31 027) NILSENE BUILDER
INC
21060 HOMESTEAD
RD 21.6 CUPERTINO,
CA 95014
OWNER'S NAME: DATE ISSUED: 11/02/2018
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;
I hereby affirm under penalty of perjury one of the following two declarations: CONSTRUCT (N) SINGLE FAMILY DWELLING - ( 2197 SF); AND
1. I have and will maintain a certificate of consent to self-insure for Worker's ATTACHED 2-CAR GARAGE ( 427 SF)
Compensation, as provided for by Section 3 700 of the Labor Code, for the
performance of the work for which this permit is issued.
have and will maintain Worker's Compensation Insurance asrovide
p d for by
Section 3700 of the Labor Code, for the performance of, the work for which this
permit is issued.
_. Sq. Ft Floor Area: 2197 Valuation: $0.00
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 31 027 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
may accrue against said City in consequence of the granting of this permit. IF W® IS NOT STARTED
Additionally, the applicant understands and will comply with all non-point WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulatio pe the Cupertino Municipal Code, Section 9. 1.8. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 11-02-2018 Issued by: Kim Dunbar
Y
Date: 11/02/2018
OWNER-
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, Busin.ess & 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; 11-02-2018
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 "All-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. 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 6.9
Section 3700 of the Labor Code, for the performance of the work for which this p 5 of the
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 pen-nit 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
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 compliance with the Cupertino Municipal Code, Chapter 9.12 and
Labor Code, .i must forthwith comply with such provisions or this permit shall the Health & Safety Code,
correct. I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a co 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 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 ARCH.I:TECT'S DECLARATION
Code, Section 9.18. 1 understand my plans shall be used as public records.
Signature Date 11-02-2018 Licensed
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1285
10801 GASCOIGNE DR CUPERTINO,CA 95014-3845(375 31 027) NILSENE BUILDER
INC
21060 HOMESTEAD
RD 216 CUPERTINO,
CA 95014
OWNER'S NAME: DATE ISSUED: 11/02/2018
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:
I hereby affirm under penalty of perjury one of the following two declarations: CONSTRUCT(N)SINGLE FAMILY DWELLING-(2197 SF);ANDATTACHED 2-CAR GARAGE(427 SF)
1. I have and will maintain a certificate of consent to self-insure for Worker's RE`tl#2-ADD STEP,LANDSCAPE CHANGED-ISSUED 3-28-2019
Compensation,as provided for by Section 3700 of the Labor Code,for the REV#1-CHANGE FIXED WINDOW IN FRONT ROOM TO BAY
performance of the work for which this permit is issued. WINDOW,CHANGE FIXED WINDOW IN BACK ROOM,ROOF LINE,
z. I have and will maintain Workers Compensation Insurance,as provided for by OVERHANG AT BAY WINDOWS 6-INCHES-REMAINING HOUSE 10
Section 3700 of the Labor Code,for the performance of the work for which this INCHES-ISSUED 12/12/18
permit is issued.
APPLICANT CERTIFICATION Sq.Ft Floor Area:2197 Valuation:$500000.00
1 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 31 027 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 I
may accrue against said City in consequence of the granting of this permit. SNOT STARTED
Additionally,the appli ant understands and will comply with all non-point WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source
Date 3-28-2019 Issued by:Kim
y Dunbar
OWNER-BUILDE DECLARATION Date: 11/02/2018
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,1 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)
z. 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:3-28-2019
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. 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. l 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
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
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 compliance with
correct. I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a constr ction 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. 1 understand my plans shall be used as public records.
Signature Date 3-28-2019 Licensed