B-2017-0461CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-201.7-0461
10792 FARALLONE DR CUPERTINO, CA 9501411453 (369 34 006) NILSENE BUILDER
INC
CUPERTINO. CA 95014
OWNER'S NAME: MAGANTI PRANAYA D AND BHARATHI
OWNER'S PHONE: 408-499-6595
LICENSED CONTRACTOR'S DECLARATION
ARATION
License Class B_ Lie. #1019073
Contractor NILSENE BUILDER INC Date 10/31/2018
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.
I hereby affirm under penalty of perjury one of the following two declarations:
t. 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.
2. 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, thea plicant understands and will comply with all non -point
source regulation flper the Cupertino Municipal Code, Section 9.18.
Signature=
DATE ISSUED: 03/22/2017
PHONE NO: (408) 993-1229
BUILDING PERMIT INFO:
X BLDG X ELECT _ PLUMB
_ MECH X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION:
TEMP POWER POLE (100 AMPS)
Sq. Ft Floor Area: I Valuation: $400.00
"N Number: Occupancy Type:
36934 006
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Date 03-22-2017 Issued by: Kim Dunbar
Date: 03/22/2017
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
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.
2. 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.
s. 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.
Signature Date 03-22-2017
Signature of Applicant:
Date: 03-22-2017
ALL ROOF COVERINGS TO BE CLASS ".
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 Ci pertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, ;elos 25505, 25533, and 25534.
Owner or authorized agent:
Date: 03-22-2017 //
SIR SIRATC, N LENDINGAGENCY
I hereby affirm that there is a construction 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
CUPERTINO
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(a)cupertino.org
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USE OF ElSFD or DUPLEX ❑ MULTI -FAMILY
BUILDING: ❑ COMMERCIAL
PROJECT IN WILDLAND ❑ YES
URBAN INTERFACE AREA ❑ NO
PROJECT IN
FLOOD ZONE
El YES
❑ NO
15 THE BLDG AA' ❑YES
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
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TOTALVALUATION:
RECEIVE
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provi d is correct. I have read the Description of Rork and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buildin o struction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: Date: 6S —2?-- T
SUPPL E FORMATION REQUIRED
OFFICE TJSE ONLY
❑ O\ ER -THE -COUNTER . -
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MAJOR
MEPMiscApp_2011.doC 7-evised-06/21/11