B-2018-1315 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMITNO:B-2018-1315
18770 TILSON AVE CUPERTINO,CA 95014-3858(375 17 039) NILSENB BU ILD ER
INC
21060 HOMESTEAD
RD 216 CUPERTINO,
CA 95014
OWNER'S NAME:TACKS SUSAN M TRUSTEE DATE ISSUED:08/03/2018
OWNER'S PHONE; PHONE NO:
LICENSED T TION BUILDING PERMIT INFO:
License Class&Lic.41019073
Contractor NILSENE BUILDER INC Date 10/31/2018 X BLDG X ELECT—PLUMB
I hereby affirm that 1 am licensed tinder the provisions of Chapter 9(commencing —MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)al'Division 3 ofthe Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
TEMP POWER POLE(100 AMP)
I hereby affirm under penalty of perjury one of the following two declarations:
r. 1 have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 ofthe Labor Code,for die
performance of the work for which this permit is issued,
_
is issued. Sq.Ft Floor Area: Valuation:$450.00
APPLICANT CE11TIF1CAT10N
I certify that I have read this appllcalion and state thatthe above
information is correct.I agree to comply with all city and county ordinances APN Number: Occupsurcy'lype:
and state laws relating to building construction,and hereby authorize 375 17 039
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 regulaI
I hereby affirm that I am exempt Pram the Contrac(or's License Law for ono of the RE-1200 FS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.if a roof is
r. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,l agree to remove all new materials fic
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sce.7044,Business&Professions Code)
z. 1,as owner of the property,am exclusively contracting wiht licensed Signahuc of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:8-3-2018
1 hereby affirm under penalty of perjury one of the following'three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
r. I have and will maintain a Certificate of Consent to self-insure Cur Worker's
Compensation,as provided for by Section 3700 ofthe Labor Cade,for the
performance ofthe work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z I have mrd 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 ofthe Labor Code,for the performance ofthe work for which this California Health&Safety Code,Sections 25505,25533,and 25534.1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9,12 and the
3. I certify that in the performance ofthe work for which this permit is issued,1 Health&Safety Code,Section 25532(x)should I store or handle hazardous
shall not employ n n in an rmer so as to become subject to the material.Additionally,should I use equipment m-devices which emit hazardous
1 y n y person y ma J 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 Cape thio Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safely
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a const tion 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 properly 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 5141 IECi'S Db:CLAttATIOry
Code,Section 9.18. 1 understand my plans shall be used as publior..
rcords.
Signature Data 8-3-2018 Licensed