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