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B-2017-1221CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-1221 10561 WUNDERLICH DR CUPERTINO, CA 95014-3660 (375 33 052) NILSENE BUILDER INC CUPERTINO, CA 95014 OWNER'S NAME: DEVIREDDY CHANDRA R AND VIJAYA L OWNER'S PHONE: 408-99-1229 LICENSED CONTRACTOR'S DECLARATION License Class 5 Lic. #1019073 Contractor NI NE BUILDER INCDate 10/31/2018 hereby affirm that I am licensed under the provisions of Chapter 9 (commencing ith Section 7000) of Division 3 of the Business & Professions Code and that my cense is in full force and effect. 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 Mperformance of the work for which this permit is issued. z. I 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. 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 and state laws relating to building construction, and hereby authorize 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 may accrue against said City in consequence of the granting of this permit. Additionally, theplicant understands and will comply with all non -point source regulatiol pJr t1pe Cupertino Municipal Code, Section 9.18. Date 07-25-2017 I hereby aftir&that I am exempt from the Contractor's License Law for one of the following two reasons: t. I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) 2 I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). 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 Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. z. 1 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. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. 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 and state laws relating to building construction, and hereby authorize 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 may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Sig Date 07-25-2017 DATE ISSUED: 07/25/2017 PHONE NO: (408) 993-1229 BUILDING PERMIT INFO: BLDG X ELECT —PLUMB MECH X RESIDENTIAL _ COMMERCIAL DESCRIPTION: P -POWER POLE (100 AMP) Sq. Ft Floor Area: I Valuation: $400.00 APN Number: Occupancy Type: 375 33 052 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. by: Kim Dunbar RE -ROOD All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without fust obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant:, Date: 07-25-2017 BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the C"ertino Municipal Code, Chapter 9.12 and the Health & Safety Code, ectidln 25505, 25533, and 25534. Owner or authorized agent: Date: 07-25-2017 CONSTR I LF N"nTNG AGENCY I hereby affirm that there is a co ruction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional COMMUNITY DEVELOPMENT DEPART HENT • BUILDING DIVISION on' 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTINO (408) 777-3228 • FAX (408) 777-3333 ^ buildina(c�dcupertino.orp MISC ❑PLUMBING 1 11lRCAANTCAT. 1( IcTR(`MTrIAT 1`7 PROJECT ADDRESS # o�1 ( n �� `1 R) o r C' IJ APN r -3 r� OWNER NAME E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX CONTACT NAME NN ®�' ��C PH EW r fy rte n E-MAIL STREET ADDRESS �6S /9 �e=CITY, STATE, ZIP �� -0 FAX F�✓ ❑ OWNER ❑ OWNER -BUILDER '❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME J? 4� LICENSE NUMBER C' (q ®�/ LICENSE YPE BUS. LIC # COMPANY COMPANY NAME ! V p i� EMAIL !'� �9 1)Rev, (� ` PC 6L STREET ADDRESS 42_1 06,1 NAC)q p S+e;,_� `� _` CITY, STATE: ZIP C y, p e f PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS 12 CITY, STATE, ZIP PHONE USE OF SFD or DUPLL-X ❑ MULTI-FAMTLY BUILDING: ❑ COMMERCIAL PROJECT IN WILDLAND ❑ YES PROJECT IN ❑ l'ES URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑ NO IS THE BLDG AN ❑ YES EICHLER HOME? ❑ NO DESCRIPTION OF WORK ell a14 , TOTAL VALUATION: RECEIV By my signature below, I certify to each of the following: application and the information I have provided is corr t ordinances and state laws relating to building construcl n. Signature of Applicant/Agent: I am the property owner or authorized agent to act on the property owner's behalf. I have read this R have read the Description of Rork and verify it is accurate. I agree to comply with all applicable local flo 'ze representatives of Cupertino to enter the above -identified property for inspection purposes. Date: C) 014 SUPPLEMENTkLjfN50kMATION REQUI.RED OFFICE USE o1vl cz - ❑;-OVER-TFIE-COUA^rEll .' U ❑ EXTRESS STANDARD El LARGE a MAJOR. _ ... . ATEPMisc14pp_2011.doc revised 06/21/11