B-2017-1913 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1913
866 BETLIN AVE CUPERTINO,CA 95014-4547(369 27 031) NILSENE BUILDER
INC
CUPERTINO,CA 95014
OWNER'S NAME: ZHU FANG AND WANG XINHUA DATE ISSUED:11/06/2017
OWNER'S PHONE: PHONE NO:(408)993-1229
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class a Lic.#1019073
Contractor NILSENE BUILDER INC Date 10/31/2018 X BLDG X 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:
(N)TEMPORARY POWER POLE(100 AMPS)
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
M / Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$500.00
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 27 031
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 app'can understands and will comply with all non-point
source regulations •-r th' upertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature / (, r1 4 Date 11/6/2017 Issued by:Jasmine Archbold
4IfDate: 11/06/2017
i . ► , . s $►
I hereby affirm•t 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: 11/6/2017
1 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
3. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should 1 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 :'y • ea Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cl ie ''no Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code, ec s 25 05,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent: �i
APPLICANT CERTIFICATION Date:11/6/2017 M W"
I certify that I have read this application and state that the above information is s► t imam!•s o. .
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a c.ar ction 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 11/6/2017 iProfessional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO CA 95014-3255
40.lD.fr _.:..
(408) 777-3228 • building@tcupertino.org PEMIT PB- 2O l1_ - l9 ( 3
CUPERTINO REVa DEFE
❑ NEW CONSTRUCTION ❑ADDITION ❑ALTERATION ❑T.T. [MEP ❑RE-ROOF ❑SWIMMING POOL/SPA
PROJECT ADDRESS Q! R 1 j /� 'e, IZIPAPN
aOWNER NAME r0.nl.] 2 hD �A�� PHONEE-MAILSTREET ADDRESSAG• G� UI Y, STATE, ,
CONTRACTOR NAME ❑OWNER-BUILDEJ�__CQMPANY NAME LICENSE NUMBER LICENSE TYPE
POSene tU'jer inC N�orG 1G 1Q0 �3
STREET ADDRESS CITY STATE, ZIP
2tc6a He r^Ps tem (d fix` 2t6 C UPI°(fii I O
E-MAIL PHONE BUS.LIC p
ni\5PieiACQ w�a;1 ,Coon it.1oe_444-69 46
❑ARCHITECT 0 OWNER ❑OWNER AGENT XCONTRACTOR AGENT 0 ENGINEER 0 DEVELOPER 0 TENANT
,
CONTACT NAME v'n^e E-MAIL
STREET ADDRESS , CITY,STATE,ZIP PHONE
q1040 vie vele Oft...4 .rd * 21 6 CvPei 4i^c gag-L-141 -694k5
DECRIPTON
7edn Q(c ry Q011 100 AM e
❑SINGLE-FAMILY/DUPLEX 0 MULTI-FAMILY 0 INDUSTRIAL 0 COMMERCIAL I
EXISTING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES I TOTAL NE7 SF USE TYPE OCC SQ.FT. VALUATION(S)
REMODEL. REMODEL KITCHEN REMODELOTHR GARAGE ❑ATTACHED
BATHROOM SF SF SF SF ❑DETACHED
EXISTNG ❑YES EICHLER 0 YES SECOND STORY ADDITION OYES
FIRE SPRINKLERS❑ NO ❑ NO 0 NO
DWELLING SECOND DWELLING 0 yES 0 ATTACHED DETACHED OTHER
UNITS it UNITADDITON: El NO SF
POOLS' 0 FIBERGLASS 0 VINYL-LINED 0 GUNITE ❑PREFABRICATED
POOL-SF SPA-SF I SPA ATTACHED ❑YES 0 NO I TOTAL-SF
EIVED BY: L. TOTAL VALUATION:
Commercial or Mulli•Famila Buildings with Public Swinnnine Pools requires Department of Environmental Heath approval w 5 0 v
RE-RO OF EXISTING ROOF TYPE: ❑BUILT-UP ROOF❑ASPHALT SHINGLES WOOD SHAKES❑WOOD S7HINGWLES❑TILE OTHER(SPECIFY)
REMOVE/REPLACE❑NO IF NO PLYWOOD ❑1„ ❑3/8" PLYWOOD TYPE: PITCH: ROOF CLASS
p YES Q OF LAYERS THICKNESS❑5/8" OTHER ❑OSB ❑CDX OTHER •12 A
PROPOSED ROOF TYPE:❑BUILT-UP ROOF DASPHALT SHINGLES 0 WOOD SHAKES❑WOOD SHINGLES 0 OTHER
*Provide a signed copy of the Cupertino's Tear-Off Policy SF sof SQUARES
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 provided is correct. I have read the Description of Work and verify it is accurate. I agree
to comply with all applicable local ordinanc s a state laws relating to building construction. I authorize representatives of Cupertino to
enter the above-identified property for inspe io u ores. I acknowledge and authorize all information contained on this application form
to be made available for public record. ,�
Signature of Applicant/Agent: Date: \1_4_ 17
SUPPLEMENTAL INFORMATION REQUIR
*New SFD/Second Dwelling Units/Multifamily Dwellings:A Demolition permit is required prior to issuance of a building permit for all new construction.
*Commercial Buildings: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project.
*Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application.
*HOA-Provide a letter of approval from the Home Owner's Association
BldgApp_2017.doc revised 08/01/17