04060037 CITY OF CUPERTINO '4Cf =' ` ^,
BUILDING DIVISION PERMIT ONTRACTnR INFORMATION
BUILDING ADDRESS: PERMITNO.
BNS CONSTRUCTION INC 04060037
G20 CYNTHIA AVE
OWNER'S NAME: PERMIT MUT DATE
E:
fARIHIT
SANITARY q9tOL NO.
ECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
l� 0
LOo LICENSED CONniACTOR'SDECLARATION Job Description
s u� 1 thereby affirm that I am licensed matter provisions of Chapter 9(commencing
with Secuon 701111)of Division 3Olson Business and professions Code,and my license is
in full folind effect.
5'qi e aLicense Class Lim.N SFDWL-SINGLE STORY
i�� cont TSDIE°r LIVING 4 , 073/GAP-AGE f/&AT
ARCHITECTS DECLARATION
1 undcrseand my plans shall be used as public records
lr
JyU
G Licensed Professional
3 OWNER-BUILDER DECLARATION
<M 1 hereby affirm that 1 am exempt tram Ne Confai License Law for the
O o following reason.(S=ums 1031.5.Business and Professions Code:Any city or county
sem tai which requires a Permit on construct.aIle,.Improve,demrllsa.or repair any structure
poor In its issuance.also requires the applicant for such permit to file a signed emumus
< that he is licensed pursuant to the pnaisioa of the Ccnto ml's license law(Chapter 9 Sq. Ft.Floor Area Vatd(]n
d000
�l=–m (commencing with Section 7000)of Division 3 of the Business and Professions Code)or DDI/
y 5 that he is exempt therefrom and the basis for the alleged cu aliftw.Any virlation of n'
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number "d6l upaney Type
sol mart Nan five hundred dollars(5500).
❑Lax ownerof ren Property,Or my employees with wages as until sole compensation 37522030 . 00
will do the work,and the swemrt is not intended ofolmred nor a.le(Son.7W,Business
and Professions Code:The Conoacmr'i Lice.Law does nm apply in an on,of Required Inspections
property who builds or improves thereon,and who doessuch work himelfor through his
own employees,provided than such improvements ammo intended in offered foram.IL
how.,the building or impmvement is sold within ore)ear of completion,me owner
Wild=will have the burden of proving that M did nm Wild or improve for purpose of
care.I
1.as owner of the pmpeny,em inclusively convecting with licensed contractors to
construct no pmjm(Sec.7014.Business and Professions Code:)The Convector's Li-
cone law does not apply to an owner of property who Wilds or improves themon,and,
who contracts for such projects with a conlracmf(s)licensed pursuant m tW Conlfanurs
Cicero¢law.
Or lam exempt under
.B h P C for this moon
Owner 2 r�L/1�2�—_ - Data
WORKER'S COMPENSATION DECLARATION
I hereby aim under penalty of perjury one of the toll 'n laration se
have and will maintain a Cerufiate of Consent in self-insure for Workers ComNn-
aation,a provided for by Section 3700 of the labor Code iZothe performance of the
work for which this permit is issued.
❑I have and will maintain Workers Compensation Insurance,as,Iequirod by Section
3700 of me lata(Code,for can PeRarmance of one work for which this permit is issued.
My Workers Compensation Insurance artier and Policy number are:
Confer: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thus section needsou becompleteddthe permit is forane h mhouldo0an(5107)
car Mss)
1 cenify than in the Performance of the work for which this Permit is issued.I shall not
employ any person in any moonier an as to become subject o the Workeri Compensation
Laws of California,Dam
Applicant
NOTICE TO APPLICANT:IL after making this Cul ifiam of Exemption,you should
become subject in the workers Compensation previsions of me labor Code,you mum
.JZ forthwith comply with such provisions or this pcon,shall W deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
(.� I hereby aRrm cos mere is a construction lending agency far the performawc of
!Y the work for which this pmmit is issued(Sce.3097.Civ.C.)
f37 0 Lendcr's Name
G Lcnder's Address
az
U Q I cenify that 1 have mad this application and sem Out the shove information is
ly F correct.l agree to comply with all city and county ordinances and sum laws rotating to
pU Wilding concoction.and hereby authorize mprescnuuves ofthis city m enter upon lW
r W =hove-amm mcd property for impatience purposes.
(We)agree m save,indemnify and I er,harmless the City of Cupertino against
H y liabilities,judgments.costs and expenses which may in any way¢cmc against said City
U Z in consequence of me granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO EREGnLATI S.
Re-roofs
Signature o Appliam/Contnctor Dam
HAZARDOUS MATERIALS DISCLOSORE Type of Roof
Will the applicant or future building Occupant store at handle haardous material
a defined by the Cupertino Municipal Code.Charter 9.12,and the Health and Safety
code.Sectien 25532(a)?
UYa All roofs shall be inspected prior to any roofing material being installed.
KN
Will theapplicant or fumm building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
-� irs vait
t hmadnus air contaminants ax defined by the Bay Arca Air Quality Management all new materials for inspection.
�t strict?
-0 yea DO'
thew meal the hvaNnusmaerials mquimmenu under Chaper6.95 of the Califon
nim Halth gr Samty Codc.Scedom 355D5,25533 avd 2 534.1 undersand theirmc Wilding
does not currently hove a meant.mat it is my responsibility to notify fee=cupanl of the
rcquiremcnu which mumvW me eo,m issuance ofa ccNEcau,of Occupancy.p Signature of Applicant Date
Owner pr thmirt agent Date All roof coverings to be Class"B" or better