08110030 CITY OF CUPERTINOmg � ::
BUILDING DIVISION PERMIT "FVo13=;1�t14TQl��INk'ORMATIO,N
?,M m.�.;„�ta_.�.�T«'vwa'.,,. .. s.i'N�.�#aalx s,•s.C;Y>d«?d
BUILDING ADDRESS: PERMIT NO.
18691 BARNHART AVE AMERICAN RESIDENTIAL o8linnin '
OWNER'S NAME: SERVICES OF CA FERMry ISSUE DATE
RV RFMTFV
CONTROL NO.
(408) 982-0405
ARCHITECT(ENGINEER: BLDG BUILDING PERMrr INFO
ELECr PLUMB MECH
0 0
�Op LICENSED COCTMACIVR'S DECLARATION lob Description
u I hereby affirm that I am licensed under provisions of Chapter 9(commixing
with Sccuan]0(10)afDiridon 3af Jte Bulinus and Prof„s'mC ganJ myliccnsus
sfullfascemdfif REPLC MN SWR LINE W/SDR17 TRNCHLESS PIP& ABS PIPE
�qz D In,ue eau L_Lieu ALL 4„
2!z Da¢ Comrxwr
eepp7W7W HnECTS DECLARATION
I os I tinders n yid +hall W used a puretic records
gDue.
19t; Licensed Profcssiand
3 OWNER-BUILDER DECLARATION
E 1 Wreby aRm that 1 am exempt from the,Contractors Lsenu Law for to
0 O following wan.(Secure 70313.Bust.aM Profeames Code:Any city or aunty
i$� which requires a peps in commucL slur,improv.demulsh,or repair any structure
fz prior to its issuance,man require the applicant forsuch permit to file a signed wtemmt
pp <
that he is licensed ptrstad N the previsions of im ComracmA Lame Law(Chapter 9 Sq.Ft.Floor Area Valuation
Y�$ (commencing with Section]000)of Division 3 of the Business and Professions Code)or 5000
Nm W u exempt therefrom and the bass the e alleged exemption.Any violation of
Section 70113 by any app0unt fin a Permit Whined the applsarua a Civil penalty of APN Number Occupancy Type
no,ream Nan five hewed dollars(M) 37526041 . 0 0
I,u owrca of and
pmpaty,in my wptendedwith cages Iter
Heb sus canpewuon,
will dotho f..I..work.ands: he Cmatructure actotseicense aw do frralopply to a4,Budinas Required Inspections
slid Profession Cade:The Contractors License Law dam rot apply lf an owner of q P
summary,who Wilda inimprowa Hereon,and who donateswork endedOmalfho forand his
owner.the Wilding
improvement
improvementsid witartnot inendidmolfeed fur cdamm,
Witterr.Nebuildinginien ofp.nlssold did one Seer of coaphtim.sW mit Of
Wildin will base she linden of proving that W did rot dtiW in improve for purpax of
sale.).
1,as owner of the propery.me eacheively contracting wit liecaad commands in
construct the project(Sec.7044.Business and Profcasmns Cade:)The Contrames Li-
ccom law docs not apply in an owner of property who Wilds or improves Nemon,and,
who ommsects fee such proj,cu with a comsacmr(s)licensed pu mum in the Contramrs
License Law.
❑I and exempt under See .B k PC for this woo
Owner Data
WORKER'S COMPENSATION DECLARATION '
I bemby afBm under penalty of perjury ons of de following decla astiam:
l have aM will maintsm a CariOute of Consent to self-insure for WinkaYf Compen- '
.it..a provided for by Section 3700 of the labor Code.for Ne perrormanden of the
whole for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,as required by Section
1]00 of Ne IaWr ode,for On Picrfornumn of the,work for which Ni,permit is Issued.
My Wa sCo pati bra ex 'nand Policy nu atq�w Q
Grrien Paltry No.: J (�
C FFXEMPf10N Fl10 WORKERS'/_�
COMPENSATION INSURANCE 6
1-01 1
(Tbisectlm neednothecompleaid if NepemitsfororohuM ddollen(5100)
or Ins)
I coniry that in use perforn.of N,work,for which this permit u issued.l shall not
employ any person in any answer an as m become subject to the Workers'Compensation
Laws of California.Dau
ApU.t
NOSICE TO APPUCANT:If,after making this C,rtiOcae of Emmpthm.you should
become subjm in the Workers Compensation provisions of the labor Code,you must
rJ Z forthwith comply with such provisions or this permit shall W deemed involved.
z O CONSTRUCTION LENDING AGENCY
[mow en I bemby affirm that dere is a construction lending agency for tW performanco of
IZ > tW wort for which this,permit Is Wood(Sec.3097,Civ,C.)
GQ Lenders Name
0 z Unders Address
U Q 1 certify,Na I haw read this application W lute Na the above information is
Iy F coma.I agree Or comply with all city and county ominarmes and sum laws relating to
pU Wilding construction,and Wmhy audiorie epresentatisys of this city in enter upon Ne
W .hove-mmdmted property for impcctim purpoxs
�'gy (We)agree to an,indemnify and keep harmless be City of Cupertino against
,.y to liabilities.judgmenu.cmu and upere.which may in any way accrue against said City
fJ z in CinlagMof fNis IemiL
�--� APPLICA DERSTAN s AND WILL 5C0 A NON-POINT Issued by: Date
SOUR EGULATIO ,r[,r
Si atm 'Canlranar D� Re-roofs �_-
HAZARDOUS MATERIALS DISCLOSUR Type of Roof
ill the applicant or fusum Wilding ac rpmt sloe or handle haardous material
,by Ne Cupertino Municipal Cade,Chapter 9.13,and the Health and Safety
Code.semen 25532(,)]
C]Y. L era All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding occupant um equipment or Jcvim which If a roof is installed without first obtaining an inspection,I agree to remove
,it his argil air canuminanu a defined by Ne Bay Area Air Quality Mmagcemm all new materials for inspection.
tries]
❑Yes u y -
I haw read the haudau materials equiemems under Clupur 6.95 ofNc Cabior.
ns HudhSafclyCodc,Smetana 255115.25533 mil 25534.1 undersand Jar if the Wilding
dm Out eumnJ that'toy responsibility m rouf t o Ne
requiem, chmuuW priormissuane Signature of Applicant Date
lien nNorissd seem ,N. - All roof coverings to be Class'W'or better
CITY OF CUPERTINO
• 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: pdtg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . .. 37526041 . 00
DATE ISSUED. . . . . . . : 11/07/2008
RECEIPT #. . . . . . . . . : BS000006570
REFERENCE ID # . . . : 08110030
SITE ADDRESS . . . . . : 18691. BARNHART AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : JAY REMLEY
ADDRESS . . . . . . . . . . : 18691 BARNHART AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : AMERICAN RESIDENTIA
CONTRACTOR . . . . . . . : DONALD KARNES LIC # 21504
COMPANY . . . . . . . . . . : AMERICAN RESIDENTIAL SERVICES
ADDRESS . . . . . . . . . . : 965 RIDGE LAKE BLVD STE 201
CITY/STATE/ZIP . . . : MEMPHIS, TN 38120
TELEPHONE . . . . . . . . : (408) 982-0405
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- -- -- ----- ------- ----------
1BSEISMICR VALUATION 5, 000 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1PPERMITFE FLAT RATE 1 . 00 40 .79 0 . 00 40 . 79 0 . 00
1PRSEWER UNITS 1. 00 20 .40 0 . 00 20 . 40 0 . 00
1TRAVDOC FLAT RATE 1 . 00. 40 . 79 0 . 00 40 . 79 0 . 00
---------- -------- ----- ----
TOTAL PERMIT 102 . 48 0 . 00 102 . 48 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------- ---------- ----
CHECK 102 .48 #8128004774
---------------
TOTAL RECEIPT 102 .48
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
- -------------------------- -- ------ ----------------
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 400 SEWER/LATERAL
507 FINAL PLUMBING
e
,.� Community Development
10300 Torre Avenue
fy %' Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
WUPERTINO
Building Department
JOB ADDR Sew PERMIT $ DO3 a
w v a�!
OWNER'S NAME: PHONE #
GENERAL CONTRACT R FAX #
I am not using any subcontractors: 8'
Oigrtgiu're I/ Dkte
Please check applicable subcontractor and c m Tete the following information
SUBCONTRACTOR SINESS 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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
•
Owner/Contractor Signature Date
CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
• CUPEkTINO PERMIT APPLICATION FORM
APN # r��s �� I I Date: 9--
Buildin dr `T
C.11�
Owner's Ne: Phone #:
M4
r
Contracctntor::^ f'�,, Phone #:
�U W Fax #:
Contact: Phone#: qC1 1,-749-
Fax
Z7Fax #:
Contractor License #: Z(ps
Cupertino Business License#: _no 0
Job Descrip ' n: n �n oy
(X" Wt� Gt uV�
Residential Commercial ❑
Valuation: — d
Project Size: Express LJ Standard LA Large ❑ Major
Green Building: Please complete relevant portion of the Green Building Checklist& attach it to the
application or if applicable, include in plan set & the sheet index.
Green Building Points:
Quantity Fee ID Fee Description Fee Permit Type
Group
1PCSEWER Commercial building P 1CPSS
sewer/sanitary sewer
113PREPIPE Commercial re-pipe per fixture P 1CPRP
1PGASCOM Commercial Gas Piping System P
1-4 Outlets
1BSEISMICOM Seismic Commercial P
1BSEISMICR Seismic Residential P
1PRSEWER Residential building P 1RPSS
/ sewer/sanitary sewer
a CITY OF CUPERTINO
REPIPE/SEWERIMAIN SERVICE
CUPERTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1PRREPIPE Residential re-pipe per fixture P 1RPRP,
1BPWSVCS Water Service P 1CPWS or.
. , 1,RPWS
1PPRSEWG Private Sewage Disposal System P
1PCESS Cesspool P
1BPWATER Install/alter Water Pipe P
1BPFDCTURE Plumbing Fixture P .
1PGASRES Residential Gas Piping System. P
1-4 Outlets
1BPGAS Gas Piping System 5+ Outlets P
( 1PPERMITFEE Plumbing Permit Fee Issuance P
1PLMBLNCK Plumbing Plan Check P •
1PLMBINSP Other Plumbing/gas Insp. P
1TRAVDOC. Travel & Documentation Fee B
l 1BUSLIC Business License B
Revised 6-16-08