05020033 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
Wgf`*
BUILDING ADDRESS: AMERICAN RESIDENTAIL SERVI PTff "'05020033
OWNER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY NO. CONTROL NO.
(408) 287-21 5
ARCHITECrIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
CD O O O
X00 LICENSEDCONnsed A ,p.WLARATION
uC I hereby affirm Net 1 3 licensed undo provisions ti Chapter 9 mylic ci is Job Description
iW withllto=Td A)ect. ion]of me Businauand Pd,m�fcTss.1iou Cade.and myliceea is
d mfane Class and Affect.
Licg�`t`V�y REPLACE PROPERTY LINE C/O (TRENCHLESS)
Dam Class
r p Date Contractor
i sJ` ARCHITECTS DECLARATION
W U I uMcrswlJ my Plans shMl he used As public mcmrda
;6
G G l,iceued Profcstionel
OWNER-BUILDER OECe C.muaON
0 0 I thereby.(firm o n I e1.exempt from Nt Canvas C s e:Any c law for tbo
i mm O following moon.(Suisun IID 1.5,Business And Rvfexsieu Code:Any city or county
_ which rcyuiru a permit to cnms de attic,impmm,demoluR or mash any tatcho d
r Z� that hes its censed e.ponso rcquims me applicant for sucCor ma idn's ccnwle a signed(Chap ens
x
< (commescanwithSection7omcpmviviounlthe ortheB smell ndProflaw(CNpar9 S F[. Floor Area Valuation
As 1- that he
exempt Section and Use
Division]nfsbo Business and Professions Anyviolaodc)of
Nn io Is exempt Nem from and for burs for the Alleged do, currant to Any it Pleuon of
Section than
L5 by Ny applicant for a permit subjects me applicant to a civil penalty or 3 7 e10 0 Occupancy Type
not mom than fire namama dollars(s5oo). p y yp
❑I,uowner of Ne pmpmy,or my wploycu with wagexu Heir mle eompeuedon,
will dOebowart,end the tuuuumunotinU orawredsActA(Sec.]06a,Bulinus
and eory who
Code The ConvumYs nd who law doe nal appy to an owner Of Required Inspections
posOwn enywho Wilds poovidmpmvu meimprimndwho Am not
vena droffeorlMugh his
ownemployee.providedmrsuch improvementsinnot icor of completion.eemA fausam.Own fir.
however,me Wilding or imprommeinu sold within one you of improor the owe of
Wilder will lose IK WNert of proving WI k did act build or improve for purpose of
talc.,
❑1,in vmer of the property.am exclusively convecting with liceued emrncmrs in
cc=La it project(See.0 in wetness and ray who Wilds
Codei The es Om
mrs and Wort law does not apply b m ower of protons who sed p on improves Corton,Nd
Lmmae Lace for such projeeu with a conuanor(s)licensed pursuant b me Conuactofs ���
Ekava law.
❑Tun exempt under See. ,Bk PC for thio moon p
Owner Date �// // �Oos
WORKER'S COMPENSATIONDECLARATION GG//�J//
1 hereby Affirmai under penalty of Perjury oro of Crc following declarations: ��
1 have and will maintain aCerufiaa of Covent toself-teem for Worker's Compcn-
7C3'1rX)
on,as provided for by Section]TOO of me labor Codc,for the performance or Co e
rt ror which this pormit is issued.
1 have and will mainuin Worker's Compensation Iruunna,u ouround by Sccuon
of me Lamar Code,for the perfamnenee Ofda work ror which this Permit u issued.
y Wowwfk--cc�rta,,CCo�om.penson..I...artier end Polity nwborrrierL"r'1� '(k1 CQ,Polity
CERTIFICATE OF SEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need vat W complcud If she Permit is for one hundrtd dollars(SI W)
or less.)
1 cenify,that in thc performance of the work for which this Permit is issued.I shall not
employ any person in any mannerm az In become subject o me Workers Compcusation
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:If,afar making this Ccrdrmau of Exemption,you should
become Subject u the Worker's Compeuauon previsions of the labor Code.you meed
.J z foMwim comply with such pmvisiou of this permis,hall W deemed revoked.
'EO CONSTRUCTION LENDING AGENCY _
F 1 hereby affirm mat mem iso couuuibm mralingegency for me Paf.drarec.if
the unions fur which this panni,is issued(Sec.]09?.Civ.C.)
(� Lander'.Name
Z I<MefsAddress
O Q 1 certify that I arse mad this ApplhraiM ePro ran sea mat Cu above cider upon u
{T. F Conan.l agree to comply with all city and county onlinaness and state laws miming to
OU abava-gconsu.d proerdhembyauthonp rtpmxnutivu of NisCity ucnter upon Cu
ra abovIiflcj cdpropcny for ex monpus xa
(We)agme to save.indemnify and p hmtless the City of Cupertino against
h liabilities,Judgmenu.eo and expeues ich may in any way ecemc rg+ins,said City
C_)Z in conuquencc of rot antmgafdta it, f' Z OJ
r.
APPLICANT
RST Re-roofs L COMPLY WITH ALL NON-POINT Issued by: Date
u
Sibnure of pplicamiContmm r ate '
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will do applicam or future Wilding occupant Mart art hmlla h.A dOmx maarial
As defined by the Cupertino Municipal Code,Chapter 9.11,and the Halm and Safety
,AAaLCode.Sauon 255]2(pl
❑Ye KNo All roofs shall be inspected prior to any roofing material being installed.
Will rot, Rant or comm Wilding occa tit IMS a If a roof is installed without first obtaining an inspection,I agree to remove
PP b W a Air mor devices whim g
.tilt harardnus air conumintanu u defined by the Bay Arca Air Quality Management all new materials for inspection.
Disvim?
❑Yes filNu
I hZl�l
aml maurials�re�}ukmcmA under Chapter 6.95oftheCalifor-
niaHcaltSceuou 25NI5,J�53]end 255]4.1 undcrsund met if the Wilding
doe,not Oman,mat i F my remmaibila,m tied[,the occupant of the
mquircmbe met si oma ofa Centimes:of O5xvit�Npen ySignature of Applicant Date
owner orauthemedagent Data All roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: PERMIT # c)dS-0 Z0 p 33
kqNMA M��
OWNER'S NAME: PHONE # 2 ,�Zi SBSO
GENERAL CONTRACTOR: FAX# 243
I am not using any subcontractors: 3 i
Signature Date
Please check applicable subcontractors and complete the following information:
66 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing ��. 2Ft�2 eL
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
�3d �
Owner/Contractor Signature Date
CITY OF CUPERTINO
30F REPIPE/SEWERS/MAIN SERVICE 05
• CUPERTINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
V
Owner's Name: Phone#:
Contractor: Phone: License#:
e6G.iE
Contact: Phone: Cupertino Business License#:
f--5 — �
Building Permit Info:
Bldg ❑ Elect ❑ Plumb 1K-
Job Description:
S" - i1 O 9c t%4 Qln
Residential ® Commercial ❑
Cost of Project: �✓
Qty. if
A licable Fee ID Fee Description Fee Group
PPERMITFEE PlumbingPermit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pb1 , Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
•