B-2019-0325 Permit CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2019-0325
10650 CULBERTSON DR CUPERTINO,CA 95014-3555(375 34 028) NILSENE BUILDER
INC
21060 HOMESTEAD
RD 216 CUPERTINO,
CA 95014
OWNER'S NAME: DATE ISSUED:07/15/2019
OWNER'S PHONE: PHONE NO:408-499-6595
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
i
License Class B Lic.#1019073
XBLDG _ELECT —PLUMB
Contractor NILSENE BUILDER INC Date 10/31/2020 — I
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing —MECH X RESIDENTIAL_COMMERCIAL I
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
NEW 2 STORY SFD(1960 SF)ATTACHED GARAGE(427 SF)PORCH
I hereby affirm under penalty of perjury one of the following two declarations: (255 SF)BALCONY(151 SF)
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.
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the perfonnance of the work for which this
permit is issued. Sq.Ft Floor Area: 1960 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 37534028 R-3(Alternate Materials)
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
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
;
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 perfonnance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will
permit is issued. v 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
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.9 If,after snaking this certificate of will maintain compliance with the
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a constr ion 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
ARCHITECT'S DECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal
a
Code,Section 9.18. I understand my plans shall be used as public records.
Licensed
Signature Date 7-15-2019