HomeMy WebLinkAboutB-2017-1762CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: 11-2017-1762
10400 STERLING BLVD CUPERTINO, CA 95014-3832 (375 24 006)
NILSENE BUILDER
INC
CUPERTINO, CA 95014
OWNER'S NAME:
DATE ISSUED: 01/31/2018
OWNER'S PHONE:
PHONE NO: (408) 9934229
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class GENERAL BUILDING CONTRACTOR Lic. #1019073
Contractor NILSENE BUILDER INC Date 1013112018
X BLDG —ELECT _PLUMB
MECH $ 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:
NEW 2 STORY SFD (2,110 SF); ATTACHED GARAGE (445 SF); 2
I hereby affirm under penalty of perjury one of the following two declarations:
PORCHES (253 SF); 2 BALCONY ( 122 SF)
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
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
Sq. Ft Floor Area: 2110
Valuation: $500000.00
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 24 006
R-3 (Custom)
representatives of this city to enter upon the above mentioned property for
Inspection purposes. (Wis) 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 again t said City In consequence of the granting of this permit.
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally, thea licant understands and will comply with all non -point
source regulatlon Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 1012018
Issued by: Abby Ayende
Date: 01/3112018
O
I hereby affirm thM 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 sale
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 (See.7044, Business & Professions Code),
Date: Ila 1/2018
I hereby affirm under penalty of perjury one of die following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1. 1 have and will maintain a Certificate of Consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Cade, for the
performance of the work for which this permit is issued.
HAZARDOUS MATERIALS DISCLOSURE
z 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 (his
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
Worker's Compensation Taws of California. If, atter making this certificate of
air contaminants as defined by the Bay Area Air Quall Management District I
will maintain compliance with the Cu rtlno Municipal Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health &Safety Code, [lana 25505, 25533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
Owner or authorized agent:
APPLICANT CERTIFICATION
Date: 3 0 8
I certify that I have read this application and state that the above Information is
O RUCTI L-----------
ND GAG
correct.
correct. I agree to comply with all city and county ordinances and state laws
I hereby affirm that there Is a con untillending 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
ARCHrrECT'S DECLARATION
Code, Section 9.18.
1 understand my plans shall be used as public records.
Signature Date 1/31/2018
Licensed -
Professional
NbTEE FOR RECORDING PURSUANT TO
GOVERNMENT CODE SECTION 27383
When Recorded Mail To:
City of Cupertino
Community Development Department
10300 Torre Avenue
Cupertino, CA 95014
24074244
Regina Aloomendnas
Santa Clara County - Clerk -Recorder
12/03/2018 11:29 AM
Titles: I Pages: 3
Fees: $0.00
Taxes: 0
Total: 10.00
III FOR HVII10,14, LW a 1011:0 M h M41 1 II 1
NO'T'ICE OF CITY REQUIREMENT TO MA'INTAfN TRE.ES
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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 D-�
On `a-1 before me, J [kL t A t N -5-v, Why
° (Here insert nameyand title of the officer) U
personally appeared LGc-o,.-
who proved to me on the basis of,setisfactory evidence to be the person(s) whose
name(s) is/are subscribed to the within instrument and acknowledged to me that
he/she/they executed the same in his/her/their authorized capacity(ies), and that by
his/her/their signature(s) on the instrument the person(s) or the entity upo"n behalf of
which the person(s) acted, executed the instrument.
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 official seal.
t�-O �9"6rt6844�` ��202uv'A'
(;
Notary Public] ignature (Notary Public Seal)
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DESCRIPTION OF THE ATTACHED DOCUMENT
(Title or description of alla`ch�ed`d�ocument)
(Title or description of attached document continued)
Number of Pages Document Date
OPACITY CLAIMED BY THE SIGNER
Individual (s)
❑ Corporate Officer
(Title)
❑ Partner(s)
❑ Attorney -in -Fact
❑ Trustee(s)
❑ Other
2015 Version www.NotaryClasses.com 800-873-9865
INSTRUCTIONS FOR COMPLETING THIS FORM
This form complies with current California statutes regarding notary wording and,
if needed, should be completed and attached to the document. Acknowledgments
from other states may be completed for documents being sent to that state so long
as the wording does not require the California nota:y to violate California notary
law.
o State and County information must be the State and County where the document
signer(s) personally appeared before the notary public for acknowledgment.
o 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).
a Print the name(s) of document signer(s) who personally appear at the time of
notarization.
o Indicate the correct singular or plural forms by crossing off incorrect forms (i.e.
he/she/ is /tee ) or circling the correct forms. Failure to correctly indicate this
information may lead to rejection of document recording.
o 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.
o 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.
:e 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 with a staple.
4:_
CALIFORNIA ALL-PURPOSE A.: :3dOWLf-DG :IEN"'t CHVIL COD;_ § 1189
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 notrthe truthfulness, accuracy, or validity of that document.
State of California
County of_,/�_ja
On �%��1�lt,Wl vZ���l�before me, ;C
Date Here Insert Name and Titl,- of the Offiee
personally appeared )/J/� 6k- k h Cil 2 k col h j 1G� X1/1
Name(s) of Signer(s)
who proved to me on the hasis of satisfactory evidence to be the persons) whose name(s) is/are
subscribed to the within instrument and acknowledged to me that he/she/they executed the same in
his/her/their authorized capacity(ies)r acid that by his/her/theirsignature(s) on the instrument the person(s),
or the entity upon behalf of which the person(s) acted, executed the instrument. -
I certify under PENALTY OF PERJURY under the laws
of the State of California that the foregoing paragraph
GRACE SCHNiIDT is true and correct.
Commission # 2095030
a� WITNESS my hand and official seal.
n Notary Public a California
z- ® Santa Clara County
My Comm. Ex'ires Foie 29, 2019 i
Signature C�� -A
Signature of Notary ;Public
Place Notary Seal Above
OP7701VAL
Though this section is optional, c®rrrpleting this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended docurnent.
Description of Attached Document� . � "JJ � 2Y-006 CkE .
Title or Type of Document: Yb.� 1 �/�/spm Document Date: f( —27--19
Number of Pages: Signer(s) Other Than Blamed Above: LriK��4 o
Capacitypes), Claimed by Signers)
Signer's Name:
❑ Corporate Officer - Title(s):
❑ Partner — ❑ Limited ❑ General
0 -Individual ❑ Attorney in Fact
Trustee ❑ Guardian or Conservator
Other:
Signer Is Representing:
Signer`s Name:
Corporate Officer Title(s):
❑ Partner — ❑ Limited ❑ General
El Individual ❑ Attorney in Fact
❑ Trustee ❑ Guardian or Conservator
Other:
Signer 119 Representing:
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ISO FEE FOR RECORDING PURSUANT TO
,P
l n,RJ LENT CO SECTION 27383
cc s( req 1,t 6
When Recorded 1D aH To:
24074245
Regina A l oormendras
Santa Clara County - Clerk -Recorder
12/03/2018 11:29 APS
Titles: I Pages: 3
City of Cupertino Fees: 0.00
Community Development Department
Taxes: : 10.00
10300 Torre Avenue ��� r� al'ii :® ���� VIVO W lhkk 11111
Cupertino, CA 95014
NOTICE OF CITE' REQUIREMENT TO NTAIN A PROTECTED LANDSCAPE
The undersigned, being the owner(s) of the property shown in the Santa Clara County Assessor''s Roll and identified as
A.P.N. 375-24-006 and addressed as 10400 Sterling Boulevard, hereby.agree(s) that the approved landscape; shall be
maintained and consistent to the approved plan in conjunction with Building Permit no B=2017-1762, and shall be in
conformance with the City's Landscape Ordinance. The applicant may consult the City of Cupertino's Planning Department
prior to any modifications to the landscape; ,however, any proposed, tree removals shall require approval by..the City of
Cupertino. Changes to the plan may be made under the following conditions:
1. Plants that have water usage requirements consistent with the City's Landscape Ordinance as determinedly the:
Water Use Classifications of Landscape Species manual; or
2. Plants that are low-water using, native to California and appropriate for use in the area by the Santa Clara Valley
Water District, Santa Clara Valley Chapter of the California Native Plant'Society, the Master Growers Santa Clara
County, or a certified Landscape Architect or ISA certified Arborist; or
3. Preparation of new landscape and irrigation plans in conformance with Chapter 14.15` (Landscape .Ordinance)
This declaration is binding on successors and assigns of the owner(s).
PROPERTY OWNER(S):
Owner's Signature- Co -Owner's Signature
Gt n a3-- YOA c
Print Owner's Name Print Co -Owner's Name.
Date Date `
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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 6 GAJ c---- 6 }
On `� `, 'Lei before me, � U --U #N
(Here insert name%nd title of the e officer) U
personally appeared RLI f,
who proved to me on the basis of satisfactory evidence to be the person(s) whose
name(s) is/are subscribed to the within instrument and acknowledged to me that
he/she/they executed the same in his/her/their authorized capacity(ies), and that by
his/her%their signature(s) on the instrument the person(s), or the entity upon behalf of
which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that
the foregoing paragraph is true and correct. _
JULIA' KINST.<
WITNESS my hand and official seal.®unf<y
` C®MMISNon 021.77456
Mi CoMin Ek " lres Jan a5, 2021
Notaroublic Signature (Notary Public Seal)
A®®ITI®NAL OPTIONAL II�F®I�I�IATI®� INSTRUCTIONS FOR COMPLETING THIS FORM
This form complies with current California statutes regarding notary wording and,
DESCIPTqI_ON qF THE ATTACHED DOCUMEN , if needed shoOd be completed and attached to the document. Acknowledgments
NR � from other states may be completed for documents being sent to that state so long
Q as the wording does not require the California notary to violate California notary
C ted '
(Title or description of attached ddcument) ® State and County information must be the State and County where the document
1-z5 - — a tb � signer(s) personally appeared before the notary public for acknowledgment.
e Date of notarization must be the date that the signer(s) personally appeared which
(Title or description of attached document continued) must also be the same date the acknowledgment is completed.
o The notary public must print his or her name as it appears within his or her
Number of Pages Document Date l0�I commission followed by a comma and then your title (notary public).
CAPACITY CLAIMED BY THE SIGNER
Individual (s)
Corporate Officer
(Title)
❑ Partner(s)
❑ Attorney -in -Fact
❑ Trustee(s)
M Other
2015 Version www.NotaryClasses.com 800-873-9885
o 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.
a 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 with a staple.
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-A-64A,1A-LY-a.� )
On /Umia-44 .c )-X :Y1gbefore me, 1-z G G
It -
Date Here Insert Name and Title of theb6cer
personally appeared � �
p Y pp El -� 1'"- i a.14
Name(s) of Signer(s)
who proved to me on the basis Qfsatisfactory evidence to be the person(s) whose narne(s) is /are
subscribed to the within instrument and acknowledged' to me that he/she/they executed the same in
his/her/their authorized capacity(ies), and that by his/her/theirsignature(s) on the instrument the person(s),
or the entity upon behalf of which the person(s) acted, executed the instrument.
l certify under PENALTY OF PERJURY under the laws
of the State of California that the foregoing paragraph
is true and correct.
GRACE SCHMIDT WITNESS my hand and official seal.
Commission # 2098030
®� N ary Public�.Cali9ornia z
Santa Clara County D ,
'6� Comm. Eu ires Feb 21, 2019 Signature
Signature of Notary ,Public
Place, Notary Sea Above
OPTIONAL
Though this section is optional, cmrripleting
this information can deter alteration of the document or
fraudulent reattachment of this, drorm to an -unintended document.
Description of Attached Document
W. 3 7,T- 2Y U061
Title or Type of Document: _
Docu►ment� Date: f (-2-�,�t
Number of Pages: Signer(s) Other
Than Nam -d Above:Staff
Ca acit ies Claimed ii Signer(s)
!� yQ ) y
Signer's Name:
Signer's Name:
❑ Corporate Officer — Title(s):
❑ Corporate Officer — Title(s):
❑ Partner — ❑ Limited ❑ General
❑ Partner — ❑ Limited ❑ General
El Individual ❑ Attorney in Fact
❑ Individual ❑ Attorney in Fact
❑ Trustee ❑ Guardian or Conservator
❑ Trustee ❑ Guardian or Conservator
❑ Other:
❑ Other:
Signer Is Representing:
Signer Is Representing:
02014 National Notary Association °wvw.National Notary.org ° 1 -800 -US NOTARY (1-800-876-6827) Item #5907