04080150 (2) CITY OF CUPERTINO .....
BUILDING DIVISION PERMIT CONTRAC'"TOR'�INFORMATION
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BUILDING ADDRESS: PERMIT NO.
BNS CONSTRUCTION INC 04080150
Ar-�n CYNTHIA AVE
OWNER'S NAME: PER UT ISSUE DATE
NE:
SANITARY OL NO.
IARcHITECtfENGINEER: BUILDING PERMrT INFO
BLDG ELECr PLUMB MECH
u0LICENSEDCONTRACR7R'SDECLARATION JobDescriptionWU1 hereby affirm that I am licensed under provisions or Chapter 9(commencing
iSection 7")ofDivision 3 ofNe Businessand ProfessionsCod>and my license isll force and of@m.nse Clasx LioN TEMP POWER TSDECL Alag. 2Contrac3����4
'y
ARCHITECTS DECLARATION AUG J
5a i 1undersand my Plansshall W used u public amoks,
0 Licensed Professional IalJjp
OWNER-BUILDER DECLARATIONin
I berchy adios that 1 am'xempl form the Contractors License Law for the
3'.
a o following aeon.(Samos 17031.5,Business and Rofevviuns Code:Any city or county
x$ which inquires a permit m construct,alam,improve,demolish,or repair any structure
esu" prior to its issuance,also requires the applicant for such permit o file a signed simmered
a: that he is licensed pursuant lobeprovisiomorbeC(mmcmr''sLoon.Lmv(Charter 9 Sq. Ft. Floor Area Valuatio
�F$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
that he is exempt therefrom and she pais for do alleged exemption.Any violation of
Section 7031.5 by airy applicant fora permit subjects be applicant to.civil penalty of 3 7k$N2,4iBtbe!0 0 Occupancy Type
not more Nan five hundred dollars(8500).
I,u owner of the porpeny,or my employee with cages as their sole compensation,
will do the work.and dMimucm,is no,intended oroffered for age(Sa.7044,Businces Required Inspections
and Professionsn
ions Code:The Commors License m e Law docs not apply an owner of q P
propeny who W ilds or improwe thereon,and whodoes suchwmk himself orNrough his
own employee,provided that such impmusmena are not intended crofRsd image.IL
however.Use building or improvement is sold within one year of completion,One owner,
builder will have be burden of proving that he did not Wild or imporw for purpose of
sal'.).
�Q,as owner of the propeny am exclusively contracting with licensed connotations to
cOmmuct the project(Sec.7044,Business and Professions Cade:)The Coorecmr's Lt.
cans Law does not apply to an Owner of property who Wilds ori arrows distant.and
who contracts for such pmjccm with acomacmrts)licensed portion,in the Contractors
License Law.
1 am exempt under Sec. .B N:P C for this reason
Owner Dam ll
WORKER'S COMPENSATION D RATION
1 hesbY'�nn under penalty of perjury one a(dla-fuing declarations
I haw and will maintain aCcelfinte of Consent m self-insure for Workers Compcm
mount xs provided for by Section 3700 of the labor Code,for the performance or the
work for which this permit is issued.
❑1 have and will maintain Workers or
Insarana,u required by Section
37IX1 of the Labor Code,Iona performance of Ne work for which this permit is issued.
My Workers Compensation Insurance artier and Policy number art:
Carer: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS"
COMPENSATION INSURANCE
(Thurretion need not W ermpleted if lo,permit is rmanchu icad dollars(81011)
or kart)
I certify that in the performance of the work for which,his peanut is issued.l shall not
employ any person in any manner xis u to Wcome subject o the Workers'Compensation
Laws of Califomia.Dau
Applicant
NOTICE TO APPLICANT:If,after making the CmUriesm Of Fsemption,you should
become subject m be Worker's Compensation previsions of the Lahr Code.you mum
� Z forthwith comply with such provisions or this permilshall W deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
I hereby affirm that Nen is a construction lending agency lnr the Performance of
be work for which this p.it is issued(Sec.3097,Civ.C.)
W A Lender's Name
6. Isnders Address
V p I certify that I have mad this City
and coon and sum that the above information is
W U cunei,.1 agree m comply with all city and county ordinances and some laws slating a
pU building cowrvcuon,and heabysuthorisarepresentatives of this city m'narupon lW
CL ahovc(We)ireursaPoultry,fm emnify on t keeppurposes.
py (We)age to saw,indemnify and keep may
in an the City of Cupenst ageism
U Z in
judgmena,Sendand expenuswhich may in any way accmc against said City
V Z Aconsequence of Ne granting.(,his permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WI'I i�,k�ON-POINT Issued by: Date
CE REGUL IONS.
✓1��/ -- Re-roofs
nature of ApplianUConuacmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant Or future building exampanl store or handle hevallous material
u de0ad by Ile Cupertino Municipal Codc.Chapter 9.12.and the Health and Safety
Code,Section 25532(.)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes 04 NO
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haxaMous air contaminants u defined by the Bay Arca Air Quality Managcmem all new materials for inspection.
District?
C1 Y. Jz No
1 have read be have bous materials requirements under Chapter 6.95 of Ne Califon
nice Health&Safety Cade.Sections 25505.25533 and 25530.1 understand lho,ifthe Wilding
docs hat cunently have a mnsnk Oral itis my responsibility W truly the occupant of be
myarmc^ts whim mum metpdorwimmana^r.ccnidnmurdeerpanay. Signature Of Applicant Dale _
V vL` 8�0
Ownerauthrriud agcm DataAll roof coverings to be Class "B" or better
SUM
CITY OF CUPERTINO
TEMP POWER 0 vs °/S
CM OF
CUPERTINO PERMIT APPLICATION FORM
APN # 3-75 - 22 - 0-30 Date:
6
Building Address: 18 63 0 G YA17W/19 AVe - CUrlor n o
Owner's Name: brd�!/rte K/)OrGS 0 f1 C Phone#:
Contractor: r3N5 C0V57-iP1)CT(04 Phone: License #:
65953 4
Contact: 3orrd N, shumLOu Phone: 409_ 605-7777 uP Certino Business License #:
Building Permit Info:
Elect ❑
Job Description:
Residential Commercia ❑
Cost of Project:
Y. i
is le Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
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