BLD-2020-0626BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 19210 TILSON AVE Cupertino
APN: 375 40 060
PERMIT NO: BLD-2020-0626
CONTRACTOR:
NILSENE BUILDER INC, 21060 HOMESTEAD ROAD #216 CUPERTINO
CONTRACTOR PHONE:
4089921229
DATE ISSUED 6/8/2020 9:39:52 AM
ISSUED BY: JASMINE ARCHBOLD
VALUATION: $9000
JOB DESCRIPTION
DEMO SINGLE FAMILY DWELLING - (1000 SF)
LICENSED CONTRACTOR DECLARATION
9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full
CONTRACTOR:
NILSENE
LICENSED
B GENERAL
LICENSED
1019073
EXP
10/31
I hereby
force
I hereby
BUILDER
CLASS:
BUILDING
NO:
DATE:
/2020
affirm
and effect.
affirm
I have and
for which
I have and
I certify that
with
INC
CONTRACTOR
that I am licensed under the provisions of Chapter
under penatiy of perjury one of the following
will maintain a certificate of consent to self
this permit is issued.
will maintain Worker's Compensation Insurance,
in the performance of the work for which
laws of California. If, after making this certificate
such provisions or this permit shall be deemed
three declarations:
-insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the
work
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's
of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith
revoked.
V
issued.
Compensation
comply
HAZARDOUS MATERIALS DISCLOSURE
Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance
I have read the hazardous materials requirements under
the Cupertino Municipal Code, Chapter 9.12 and the
V
with
equipment
Municipal
Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use
as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino
Sections 25505, 25533, and 25534.
for this project.
Firm Certification No:
or devices which emit hazardous air contaminants
Code, Chapter 9.12 and the Health & Safety Code,
An EPA Lead -Safe Certified Renovator will be responsible
Firm Name:
No EPA Lead -Safe Certified Firm is required for this project.
Certified
v
CONSTRUCTION LENDING AGENCY
lending agency for the performance of the work which this permit is issued (Section 3097, Civil Code).
Lender's Address:
I hereby
Yes
affirm
under penalty of perjury that there is a construction
No
V
Lender's
Name:
APPLICATION CERTIFICATION
above information is correct. I agree to comply with all city and county ordinances and state laws relating to building
to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep
costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,
source regulations per the Cupertino Municipal Code, Section 9.18.
I certify that I
construction,
harmless the
the applicant
.........
have read this application and state that the
and hereby authorize representatives of this city
City of Cupertino against liabilities, judgements,
understands and will comply with all non -point
Every permit issued shall become invalid unless the work on the site authorized by such permit is commenced within 365 days after its issuance, or if the work authorized on the site by such permit is suspended or abandoned for a period
of 365 days after the time the work is commenced.