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B-2017-0281 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0281 10720 CULBERTSON DR CUPERTINO,CA 95014-3559(375 34 022) NILSENE BUILDER INC CUPERTINO,CA 95014 OWNER'S NAME: DATE ISSUED:09/05/2017 OWNER'S PHONE: PHONE NO:(408)993-1229 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class j3 Lic.#1019073 Contractor NILSENE BUILDER INC Date 10/31/2018 X BLDG _ELECT _PLUMB MECH x RESIDENTIAL_COMMERCIAL 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. JOB DESCRIPTION: CONSTRUCT(N)2 STORY HOUSE(1972 S.F.);ATTACHED 2 CAR I hereby affirm under penalty of perjury one of the following two declarations: GARAGE(429 S.F.);PORCH(800 S.F.);DECK(110 S.F.) 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 'T Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area: 1972 Valuation:$434000.00 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 375 34 022 R-3(Custom) 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 regulation. 'p-,r,the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Sig nature Date:09/05/2017 OWNER-BUI R DECLARATION 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 Signature of Applicant: contractors to construct the project(Sec.7044,Business&Professions Code). Date:09/05/2017 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 performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the s. I 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 shall not employ any person in any manner so as to become subject to the material. Additionally,should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupe tino Municipal Code,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code ec o u.25505,25533,and 25534. Labor Code,I must forthwith comply with such provisions or this permit shall ' APPLICANT CERTIFICATION • Date:09/05/2017 I certify that I have read;this application and state that the above information is a sLL S •UC II LEG:GE CY correct.I agree to comply with all'city and county ordinances and state laws I hereby affirm that there is a con uction 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 and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION Code,Section 9.18. I understand my plans shall be used as public records. Licensed • Signature Date 09/05/2017 Professional ,�NQ FEE FOR RECORDING PURSUANT TO dOVERNMENT CODE SECTION 27383 When Recorded Mail To: City of Cupertino Community Development Department 10300 Torre Avenue Cupertino, CA 95014 Regina A l oomendras Santa Clara County - Clerk -Recorder 07/13/2018 11:49 ASB Titles: I Pages: 4 Fees: 0.00 Taxes: 0 Total: 10.00 NOTICE OF CITY RIEQUIR EMENT TO MAINTAIN TREES 5tri?� I�f' to _ i ` C 91. j -1pB!0 If16,9 tr98fp18� Il B O , Ej0 IOB� e y °ed + Y n,;.Y ::.i ,_r L i;�+f J� '�1 fJ ,.�f-fir L{'Y I�Y_� ast tl "-' C"r1 �'•�3 �. ,:g. ws+,r® ;p,��uetl Ito q,e ;� t�a�e ba�us �f s�,tasfr�, At®any ,eua�,el W t .bet I:'3'W�IBI�'I{I1S'p1G111,Ir1�IG1L� fed it0 _,,� Ithr'I' r1��I�rle(�) . .'.:��,� r o :.i,j r, „I� �, r.a 'irrY, �1� ., r;�3 ipr ., - u he/�shie%they execaatfod the �ar�, IIS hl�slaber/tb.o,�i r��t f®,� uze ; caloa(caty�(�sle�),, � d nth aby a v'-' j .. 13 h�Is/ e1rr/ ��alr ���a Irn�,tu�rrtetQs)',o,� tie ,�ihst �al�no ,t the-oor bel �whl����h 4�'Y O�� IPR?EIR��J�'Y t l�.d�er, Ihea 111 +off ��h� ,tt��t� o,f (07--N t� � M ; �1�e t lairng I K,009 � �h l `s it, LY RIS l0 ' { 7 ,y: hYala�}. zel i{calmei9, _ �. ���r® NOTAR PuuSuc iwl. 'Not' P�gpllcSlgn''ure (+Not�a;P,yPubhcS:eal) ' INS, ST. '-It"I "- FSR' O� ET'INiG Ta I'S`:F+Oaf Thzsformcomplteswtth currentCarlajo7naastaPutesrega'dangnotary,wordrng,and; + %: •' -y�' � , ,� ,`�� _ + '� ,' � '� ;, n +needed shozr�l�d'be cqm leted and rattached,>to 8he docun_tent A+clrirowledginents ` IIQE`�S;C�RIIPT9;q�r?OE THIE P,TTAC'H'ED��®QC>UfMEN,T f - n _ ' "' ' ` , ' f oir other states ma���be comp,�leted for %p'ocum�n!ts bevng sent>to that state so long: as alae wor di -ng does•�riot r eq -u -tire the Ca?lrfor mia. no,Gar�� to, vrolate .CabtTormra>notd%ry + law j(Tltiegr�liesenpfion`of�tt�ChedoCUmeYit+) a State and County rnfonnatron mustlbe the State and Q ounty where the document srgner(s) personally ap ", T, before+the notary pablre for acknowledgment v Date co'f notanriation must be rhedate that +the srgner(s) ipersonailily appeared which 1(TIt►e orftleseripflon rof aYtached'doC,U ent oontinue;) must also Ibe the same date,tlre racknow�ledlgment rs completed. ®e notary ,public to nnt hr+s or lher name as rt appears wrthm this or :her INumb�r of Pages _ �ocu + 1 end imp eommission followed by a comma and then your trtle'(notary public.). ® Print the rname(sj) Qf document srgnr(s) w)ro peas©riall'ly appear at +the time of notarazafion, =l — �'T I i =: ®�rrclrcate the correct smgular;or,lufa+1 forms 1.y orossrig off in'correCt forms (r ,e, CAP'Acca9TY ,C17AIiI.E,D {�V ThilE .S,acG�lE, heshe%they, is /) or5crricl`ing {the correct forms Farilue to correctly mdreafe this 0 �IYlalvBdt�l�0 I(�S� informatron,may lead to rejeGtl`Ori Ofjd'oGUmeriY recording �ir�Or�it �Ifitll,C the notary seal rmpressron, must be clear rand +photographrcally reprodueilble. findiressron must not cover tiext or {lutes If searl rmpression §mridges, re_seal,l+f;a T. suffi'crent artearpermlts, otheri rse oomplete a di+fferLent acknowledgment form i (T1tt+9e)' Si+gnature of the notary public must,matgh tl�e signature onle'wxth theoffice of Pc$Irt+Yler(S� nth colmUy clerk I �ttorney ;l'Gl ��C Additronal ;mformatron is not required brit could Ahelp to ensure this r acknowledgment is not rrusused or attached to a di+ffef- ri document o° Indreate title or typeof attached document numberrofrpages+and hate Other ° Indicate the {capacity rc'launed'Iby 5the silgner If the alarmed capacity is, a _ corporate �fFoar indicate the,tr'tlei(r ei CPEO, CIFO SearetaryJ),. 2015 U'ersiol� vvwrrd {�otaryGlasses corn 800 873 9$65 'Securely ch 'i ocurr�erit to the,:srgned document with a staple: 'I S 5Pu �{ante owl �,,d et ere a'e narge:an hh- j - YiuIN�.��3�i�u'�+iC.r/+au�9lGai�u .a,u�.'v��u su euigcr,;u �.,��s �,.,v� _.`�; _o. - •, —�.+9– - --.- wh�ll`,� �tihe ��e���®,w��'�:) a�C'e, etixcut�d it�E�e aA�$ie�,to f, lfr�s�ndie� iI�IR I il' .a u,nidieirhYe B'a�� o attire ,ra,e,.®�f r,ai6rl�for, +a 1th,ait Co'�rcte �Ot a' 'PllbltiC rS'I a s®E�'S''CRI(PT1e�ON tQ,F" TH(E 7P,��TTr4CP-IiE 1 i a(Title'for�descnptiom of aB'd "d {document) 11(Tille�o��descmptipn�oftattached dpcumentac POW( ,Pages DUo'cumen a �( f title;)` ID Atfi®rney h, ,FRaa t � 'rrU�tee�gS>) 2015 Uersig]IM wv{�atary,Cl�sses,c© � Sy�'�.'U�" ® -� Th%is for m eorizphes with ctlr remt Cailmlot n,aa statutes n egar dtng notary wordzng and; MT tf,»eeded shoubd be compl'eded and atEached,to the document AckxotNledgmerits fi o»z other slates maj? be completed IS 11 sent to that state: o long. as the wor drtg.does rtot r eguire the CalrfoJnta:riotat�r i© vrolaGe Calrforrytik- raotaiy i lativ: m Sfate and County rriforhiatron must'be the State and County where the document ' sngner(s)jpersonailly appearted'before the notaryapubhc dor;acknowledgment a Date of notanzatron must Ibe,the date'that the sz'gner(s) personably appeared Which must also alie the same date the acknowl`edrgmentis completed e Tthe notary publac must punt this or her name as it'iappears within 'his or her commission followed lbyt�a icomma and then your atrt�le (notary;pnbhc) ® Punt the namr;(s) •of dowho personally appear at alie .time of rotart�ation: m Indicate the correcf smguilar or,plutal forms +by +crossing ,off 3ncorrSect forms (1 e. l/she/tly- is /a;)ror circlmgathe cbmect forms Fa»lure+torcori�ctly inhcate thi_ s iri%rrnatnon,may dead to,rrejectr'on of document recording { The ,notary seal g impression imust be clear Fand photoraphic- ly tep oducmble. i, �Iinpr�ession must not cover Text ,or dines �I¢' s�a�l ,impression smudges, re seal tf a suf£icientarea,perinits, orhenutse com"pl'ete a dvfferenttaclmowhdgment form ® Signature of the notary ;publI mustmatch fihe s�gnatp e'on fide with the offioe ;qf the county clerk ,00 Additional mformation is not required 01 codul7help to ensure this acknowledgment is `not misused or attached to a different document o Indicate,title or type of 1attached document numberrof pages and date. <go Indioate ithecapacitay clauncd'abP. y the signer If the claimed capacYty is -a corporate officer, uzdicate rhe title (i e tCE®,, CaFO,'Searetary); M ®`S'�currly attachths document,to,tlie signed document wzth a staple. �� ...-•-.` .... _.. ., �.. __moo ,...,.. ., - � �.,.... r. .. .. ,.. .. _.:.... ..._....- - - x 5Pu �{ante owl �,,d et ere a'e narge:an hh- j - YiuIN�.��3�i�u'�+iC.r/+au�9lGai�u .a,u�.'v��u su euigcr,;u �.,��s �,.,v� _.`�; _o. - •, —�.+9– - --.- wh�ll`,� �tihe ��e���®,w��'�:) a�C'e, etixcut�d it�E�e aA�$ie�,to f, lfr�s�ndie� iI�IR I il' .a u,nidieirhYe B'a�� o attire ,ra,e,.®�f r,ai6rl�for, +a 1th,ait Co'�rcte �Ot a' 'PllbltiC rS'I a s®E�'S''CRI(PT1e�ON tQ,F" TH(E 7P,��TTr4CP-IiE 1 i a(Title'for�descnptiom of aB'd "d {document) 11(Tille�o��descmptipn�oftattached dpcumentac POW( ,Pages DUo'cumen a �( f title;)` ID Atfi®rney h, ,FRaa t � 'rrU�tee�gS>) 2015 Uersig]IM wv{�atary,Cl�sses,c© � Sy�'�.'U�" ® -� Th%is for m eorizphes with ctlr remt Cailmlot n,aa statutes n egar dtng notary wordzng and; MT tf,»eeded shoubd be compl'eded and atEached,to the document AckxotNledgmerits fi o»z other slates maj? be completed IS 11 sent to that state: o long. as the wor drtg.does rtot r eguire the CalrfoJnta:riotat�r i© vrolaGe Calrforrytik- raotaiy i lativ: m Sfate and County rriforhiatron must'be the State and County where the document ' sngner(s)jpersonailly appearted'before the notaryapubhc dor;acknowledgment a Date of notanzatron must Ibe,the date'that the sz'gner(s) personably appeared Which must also alie the same date the acknowl`edrgmentis completed e Tthe notary publac must punt this or her name as it'iappears within 'his or her commission followed lbyt�a icomma and then your atrt�le (notary;pnbhc) ® Punt the namr;(s) •of dowho personally appear at alie .time of rotart�ation: m Indicate the correcf smguilar or,plutal forms +by +crossing ,off 3ncorrSect forms (1 e. l/she/tly- is /a;)ror circlmgathe cbmect forms Fa»lure+torcori�ctly inhcate thi_ s iri%rrnatnon,may dead to,rrejectr'on of document recording { The ,notary seal g impression imust be clear Fand photoraphic- ly tep oducmble. i, �Iinpr�ession must not cover Text ,or dines �I¢' s�a�l ,impression smudges, re seal tf a suf£icientarea,perinits, orhenutse com"pl'ete a dvfferenttaclmowhdgment form ® Signature of the notary ;publI mustmatch fihe s�gnatp e'on fide with the offioe ;qf the county clerk ,00 Additional mformation is not required 01 codul7help to ensure this acknowledgment is `not misused or attached to a different document o Indicate,title or type of 1attached document numberrof pages and date. <go Indioate ithecapacitay clauncd'abP. y the signer If the claimed capacYty is -a corporate officer, uzdicate rhe title (i e tCE®,, CaFO,'Searetary); M ®`S'�currly attachths document,to,tlie signed document wzth a staple. CALIFORNIA ALL-PURPOSE CERTIFICATE OF ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of � ft tyt � iLM On , (%�( �Z � before me, C�i:LQ�Q I u tttV'1�, ,Notary Public, (Here insert name and title of the officer) personally appeared E J� who proved to me on the basis of satisfactory evidence to be the ers , s) whosq�n (s) ls/are subscribed to the within instrument and acknowledged to me tha he/they executed the same in` us her/theirauthorized K pace (ies), and that by his% er/their ' na (s) on the instrument the rson ), or the entity upon behalf of h , s`6�' ,) acted, executed the ins ent. I certify under PENALTY .OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and officia seal. (Notary Seal) Signa re of Notary Public ADDITIONAL OPTIONAL INFORMATION DESCRIPTION OF TEE ATTACHED DOCUMENT (Title or description of attached document) (Title or description of attached document continued) Number of Pages Document Date (Additional information) CAPACITY CLAIMED BY THE SIGNER ❑ Individual (s) ❑ Corporate Officer (Title) ❑ Partner(s) ❑ Attorney -in -Fact ❑ Trustee(s) ❑ Other INSTRUCTIONS FOR COMPLETING THIS FORM Any acknowledgment completed in California must ,contain verbiage exactly as appears above in the notary section or a separate acknowledgment form must be properly completed and attached to that document. The only" exception is if ` a document is to be recorded outside of California. In such. instances, any alternative acknowledgment verbiage as may be printed on such a document so long as the verbiage does not require the notary to do something that is illegal for a notary, in California (i.e. certifying the authorized capacity of the signer). Please check,the document carefully for proper notarial wording and attach this form if required. • State and County information must be the State and County where the document signer(s) personally appeared before the notary public for acknowledgment. • Date of notarization must be the date that the signer(s) personally appeared which must also be the same date the acknowledgment is completed. a The notary public must print his or her name as it appears within his or her commission followed by a comma and then your title (notary public). • Print the name(s) of document signer(s) who personally appear at the time of notarization. a Indicate the correct singular or plural forms by crossing off incorrect forms (i.e. he/she/they—, is /are ) or circling the correct forms. Failure to correctly indicate this information may lead to rejection of document recording. The, notary seal impression must be clear and photographically reproducible. Impression must not cover text or lines. If seal impression smudges, re -seal if a sufficient area permits, otherwise complete a different acknowledgment form. a Signature of the notary. public must match the signature on file with the office of the county clerk. Additional information is not required but could help to ensure this acknowledgment is not misused or attached to a different document. Indicate title or type of attached document, number of pages. and date. Indicate the capacity claimed by the signer. If the claimed capacity is a corporate officer, indicate the title (i.e. CEO, CFO, Secretary). o Securely attach this document to the signed document C 2004-2015 ProLink.Signing Service, Inc. —All Rights Reserved www.ThePmLink.com — Nationwide Notary Service