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B-2016-2257CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-2257 10792 FARALLONE DR CUPERTINO, CA 95014-4453 (369 34 006) NIISENE BUILDER - INC CUPERTINO, CA 95014 OWNER'S NAME: MAGANTI PRANAYA D AND BHARATHI DATE ISSUED: 04/19/2017 OWNER'S PHONE: 408-439-3294 PHONE NO: (408) 993-1229 LICENSED CONTRACTOR'S DECLARATION - BUILDING PERMIT INFO: License Class B Lic. #1019073 Contractor NILSENE BUILDER INC Date 10/31/2018 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: CONSTRUCT NEW 2 STORY HOME (2805 S.F.); GARAGE (434 S.F.) 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 -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. Sq. Ft Floor Area: 3239 Valuation: $400000.00 . 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 369 34 006 Deferred Submittal (R -3),R-3 (Custom),R-3 (Custom),U representatives of this city to enter upon the above mentioned property for (Private Gar /Ag Bldg),Deferred Submittal (R - inspection purposes. (We) agree to save indemnify and keep harmless the 3),Deferred Submittal (R-3),Deferred Submittal (R - City of Cupertino against liabilities, judgments, costs, and expenses which 3),Deferred Submittal (R-3),Deferred Submittal (R - may accrue against said City in consequence of the granting of this permit. 3),Dcferred Submittal (R-3),Dcfcrred Submittal (R - Additionally, the ppfi ant understands and will comply with all non -point 3),Deferred Submittal (R -3),U (Private Gar /Ag Bldg) source regulatio pe a Cupertino Municipal Code, Section 9.18. PERMIT EXPIRES IF WORK IS NOT STARTED "signature Date 4/19/2017 16 WITHIN 180 DAYS OF PERMIT ISSUANCE OR lf OWNER_ 180 DAYS FROM LAST CALLED INSPECTION. I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: Issued by: Abby yende 1. I, as owner of the property, or my employees with wages as their sole Date:04/19/2017 compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) RE -ROOFS: 2. I, as owner of the property, am exclusively contracting with licensed All roofs shall be inspected prior to any roofing material being installed. If a roof is contractors to construct the project (Scc.7044, Business & Professions Code). installed without first obtaining an inspection, I agree to remove all new materials for I hereby affirm under penalty of perjury one of the following three declarations: inspection. 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 Signature of Applicant: - performance of the work for which this permit is issued. Date: 4/19/2017 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 ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER permit is issued. s. I certify that in the performance of the work for which this permit is issued, I HAZARDOUS MATERIALS DISCLOSURE shall not employ any person in any manner so as to become subject to the - I have read the hazardous materials requirements under Chapter 6.95 of the Worker's Compensation laws of California. If, after making this certificate of California Health & Safety Code, Sections 25505, 25533, and 25534. I will exemption, I become subject to the Worker's Compensation provisions of the maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Labor Code, I must forthwith comply with such provisions or this permit shall Health & Safety Code, Section 25532(a) should I store or handle hazardous be deemed revoked. material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I APPLICANT CERTIFICATION will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and I certify that I have read this application and state that the above information is the Health & Safety Cade, cti ns 25505, 25533, and 25534. 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 Owner or authorized agent: to save indemnify and keep harmless the City of Cupertino against liabilities, Date: 4/19/2017 judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands CO STRLENDINGAGENCY I hereby affirm that there is a cons etion lending agency for the performance and will comply with all non -point source regulations per the Cupertino Municipal of work's for which this permit is issued (Sec. 3097, Civ C.) Code, Section 9.18. Lender's Name Lender's Address Signature Date 4/19/2017 ARCHITECT'S DECLARATION I understand my plans shall be used as public records.