B-2018-1303 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:3-2018-1303
21821 WOODBURY DR CUPERTINO,CA 95014-1147(326 19 121) B C S CONSTRUCTION
INCORPORATED
WATSONVILLE,CA
95077
OWNER'S NAME:BEMIS TYAND LAURA M TRUSTEE DATE ISSUED:08/01/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lia#579300 X BLDG_ELECT X PLUMB
Contractor B C S CONSTRUCTION INCORPORATED Date 10/31/2019
I hereby affirm that I am licensed under the provisions of Clmpter 9(commencing X MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code anti that my
license is in full force and effect. JOB DESCRIPTION:
REPLACE 40 GAL WATER HEATER(SAME LOCATION);
1 hereby affirm wider penalty of perjury one of the following two declarations: RELOCATE/REPLACE FURNACE TO GARAGE
3700 ofthe Labor Code,for the performance ofthe work for which this
permit is issued, Sq.Ft Floor Area: Valuation:$4500.00
APPLICANT 1 E1'11 FiCAT10N
I certify that I have read this application and state that the above
information Is correct.I agree to comply with all city and county ordinances APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 326 19 121
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We)agree to save Indemnify and keep harmless the
City of Cupertino against liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulatiiiooins per tha Cupertino Municlpal Code,Send on 9.1 6. 180 DAYS FROM LAST CALLED INSPECTION.
Signature � Date$_1-2018 Issued by:Kim Dunbar
Date:08/01/2018
OWNER-BUILDER DF,CLARA:HON
I hereby affirm that I am exempt from the Contractor's License Law for ane of the RE-ROOFS:
following two reus.mu All roofs shall be inspected prior to any roofing material being installed.Its roof is
1. 1,as owner of the property,or my employees with wages as their sole installed without first obtaining am inspection,l agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Scc.7044,Business&Professions Code)
2. 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant
contractors to construct the precct(Sec.7044,Business&Professions Code), Date:8-1-2018
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
n. 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 the
performance ofthe work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
2. I have and 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 At Safety Code,Sections 25505,25533,and 25534.I will
Permit is issued, maintain compliance with the Cupertino Municipal Code,Chapter 9.12 rand tire
s. I certify that in the performance of the work for which this permit is issued,I health&Safety Code,Scotto.25532(x)should I stare or handle hazardous
shall not employ any person in any manner so as to become subject to the material.Adel...lly,should I use equipment or devices which craft hazardous
air contaminants as defined by the Bay Area Air Quality Management District 1
Worker's Compensution laws of Celibanda.Ir,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Componsation provisions ofthe the Health&Safety Code,Sections 25505,25533,and 25534.
Labor Code,l must forthwith comply with such provisions or this permit shall
...�
APPLICANT CERTIFICATION Date:8-
I certify that I have read this application and state that the above Information is CONSTItMOON LENDING ALEN
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction 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 property 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 ARC1fITECT'S DECLARATION
Code,Section 9.1 B. 1 understand my plans shall be used as public records.
SignatureLicensed
Data 8-1-2018
Professional