D-2019-0025 CITY OF CUpER
TINO BUILDING PERMIT
MjT
�UI LDII'SON DR CUPERT
/10()-50 CTO,CA 95014-3555(375 34 028) CONTRACTOR:
PERMIT NO:D-201 9_0025
NILSENE BUILDER
INC
21060 HOMESTEAD
RD 216 CUPERTINO,
OW s NAME: CA 95014
Dp�R'S PHONE: DATE ISSUED:05110/2019
ticense
ENSED CONTRACTOR'S DECLARATION PHONE NO:408-499-65c�5
Class B Lic.#101_____907-3
BUILDING PERMIT INFO:
Contractor NILSENE BUILDER INC Date 10/31/2020 —BLDG —ELECT
I hereby affirm that I am licensed under the provisions of —PLUMB
with Section 7000)of Division 3 of the Business&Professions
9(commencing —MECH X RESIDENTIAL
license is in full force and effect. ons Code and that my --COMMERCIAL
JOB DESCRIPTION:
I hereby affirm under penalt of er•
Y p fury one of the following two declarations: DEMO EXISTING HOUSE(1100 SF
1. I have and will maintain a certificate of consent to self=insu )ATTACHED G
Compensation,as provided for by Section 3700 of the re for Worker's GARAGE(200 SF)
performance of the work for which this ermit is issued.Ie Labor Code,for the
2. I have and will maintain Worker's Compensation Insu
Section 3700 of the Labor Code,for the performance of the as provided for by
rmrt is issued. work for which this
APPLICANT CERTIFICATION Sq.Ft Floor Area: Valuation:$8000.00
I certify that I have read this application and state that the above
information is correct. I agree to comply with all citya
and state laws relating to building construction,annd county ordinances APN Number:
representatives of this city to enter upon the abovehereby authorize 375 34 028 Occupancy Type:
inspection purposes. (We)agree to save indemnifyandtkned property for
City of Cupertino against liabilities,judgments, costs keep harmless the
may accrue against said City in consequence of the g granting andofthis
expenses which PER
Additionally, the appli ant understands and will g ng of this permit. MIT EXPIRES IF WO
source regulations
Municipal Code, Section 9.18. WITHIN 180 DAYS OF pE STARTED
180 D RMI jSSU
DAYS FROM LAST CA ANCE OR
Signature CALLED INSPECTION.
Date 5/1___oi1 9 E'CTION.
Issued by:Ha--&LMcKee
O"TNER-BUILD R ECLARATION Date:05/10/2019
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
1. I,as owner of the Property,or any employees with wages a All roofs shall be inspected prior to E-ROOFS:
g s their sole installed without first obtaining an Inspection
ctO°fi11g materiel being
compensation,will do the work,and the stnrcture is not intended o
p on,I agree to installed.If a roof is
sale(Sec.7044,Business&Professions Codc) r offered for g remove all new materials
2. I,as owner of the property,ant exclusively contractinginspection. for
contractors to construct the project(Sec-7044,Business with licensed Signature of Applicant:
ess&Professions Code). Date:5/10/19
I hereby affirm under penalty of perjury one of the follow'
i. I have and will maintain a Certificate of Consent to sel thee declarations:
Compensation,as provided for by Section 3700 of the La sure for Worker's ALL ROOF COVERINGS TO BE CLASS "
performance of the work for which this permit is is bOi Code,for the `���OR BETTER
2. I have and will maintain Worker's Compensation Insurance,
as provided for by I have read the HAZARDOUS MATERIALS DISCLO
Section 3700 of the Labor Code,for the performance of the hazardous materials SURE
permit is issued. work for which this California Health&Safety Code,Sections ements under
3. I certify that in the performance of tile maintain compliance with 25505,2 Chapter 4. of the
the Cupertino Municipal C®533,and 25534. I will
e work for which this permit is issued,I Health&Safet
shall not employ any person in any manner so as to become 3 Code,Section 25532(a)should I e o deq Chapter 9.12 and t
subject to the material. Additionally,should I use equipment or device he
Worker's Compensation laws of California. If,after makinga or handle hazardous
this certificate of air contaminants as defined by the Bay Area Air Ices which
exemption,I become subject to the Worker's Compensation provisions Quality Management
hazardous
will maintain compliance with the Cupertino Mun' '
Labor Code,I must forthwith comply with such provisions or rsrons of the the Health&Safety lel al nagement District I
r this permit shall ety
AGENCY
�enter upon the above mentioned properlfor inspection
representatives of this city re is icon tr d( lending agency
Of work's for which this permit is is ued SeC Y for the
�save indemnify and keep harmless the City of C pection purposes. (We)agree Lender's Name ( 3097, Civ C performance
idgments, costs,and expenses which may ac Cupertino against liabilities, )
�nsequence of the granting of this permit.yAdd do against said City in Lender's Address
�d will comply with all non-point source regulations per�the applicant understands
ode, Section 9.18. p r the Cupertino Municipal
ARCHITECT'S DECLARATION
understand my plans shall be used as ubli
gnature P c records.