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11010002CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 1087 S STELLING RD CONTRACTOR: AMERICAN RESIDENTIAL PERMIT NO: 11010002 SERVICES OF CA OWNER'S NAME: MARY RAW 965 RIDGE LAKE BLVD STE 201 DATE ISSUED: 01/03/2011 :R'S PHONE: 4082539900 MEMPHIS, TN 38120 PHONE NO: (408) 982-0405 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT r PLUMB License Class 6 Lic. # / 65-15J MECH r RESIDENTIAL r COMMERCIAL F �L3 p Contractor / IILV )&6we V—ooWDate JOB DESCRIPTION: 20' SEWER LINE REPLACEMENT WITH 2-WAY CLEANOUT I hereby affirm that I am licensed ander the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions PROPERTY LINE CLEANOUT REPLACEMENT Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self-insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this Sq. Ft Floor Area: ,,V ation: $6850 permit is issued. fi � APN Number: 36222002.0 Occupancy Type: APPLICANT CERTIFICATION 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 and state laws relating �.4�aa xyi to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection u oses. (We) agree to save p p purposes. PERMIT E P SIF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities, judgments, WITHIN 180 AYS OF PERMIT ISSUANCE OR costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code, Section 9.18. 7 __� Issued by:- " --� _'�' __..._ Dater —� Signature_ Date I J Li OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for the following two reasons: I, as owner of the property, or my employees with wages as their sole compensation, inspection. will do the work, and the structure is not intended or offered for sale (Sec.7044, Date: Business & Professions Code) Signature of Applicant:" 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE I have and will maintain a Certificate of Consent to self-insure for Worker's I have the hazardous materials requirements under Chapter 6.95 of the Compensation, as provided for by Section 3700 of the Labor Code, for the read California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & I have and will maintain Worker's Compensation Insurance, as provided for by Safety Code, Section 25532(a) should I store or handle hazardous material. Section 3700 of the Labor Code, for the performance of the work for which this Additionally, should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued, I shall maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health & Safety Code, Sections 25505, 25533, and 25534. Compensation laws of California. If, after making this certificate of exemption, I Owner or authorized agent: t become subject to the Worker's Compensation provisions of the Labor Code, I must Date: 1 forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct. I agree to comply with all city and county ordinances and state laws relating for which this permit is issued (Sec. 3097, Civ C.) to building construction, and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes. (We) agree to save -mify and keep harmless the City of Cupertino against liabilities, judgments, Lender's Address and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply ARCHITECT'S DECLARATION with all non-point source regulations per the Cupertino Municipal Code, Section I understand my plans shall be used as public records. 9.18. Signature Date Licensed Professional 5 ITEMS OF 5 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 36222002.00 DATE ISSUED.......: 01/03/2011 RECEIPT #......... BS000012362 REFERENCE ID # 11010002 SITE ADDRESS .....: 1087 S STELLING RD SUBDIVISION ....... CITY CUPERTINO IMPACT AREA ....... OWNER MARY RAW ADDRESS ..........: 1087 S STELLING RD CITY/STATE/ZIP ...: CUPERTINO, CA 95014 OPERATOR: patg COPY # : 1 RECEIVED FROM ....: DANIEL TEHRANI 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 ---------- 1BCBSC ------------- VALUATION ---------- 6,850.00 ---------- 1.00 0.00 1.00 0.00 1BSEISMICR VALUATION 6,850.00 0.69 0.00 0.69 0.00 1PPERMITFE FLAT RATE 1:00 42.00 0.00 42.00 0.00 1PRSEWER UNITS 1.00 21.00 0.00 21.00 0.00 1TRAVDOC FLAT RATE 1.00 42.00 0.00 ---------- 42.00 ---------- 0.00 ---------- TOTAL PERMIT ---------- 106.69 0.00 106.69 0.00 METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT : AMOUNT --------------- 106.69 --------------- 106.69 VOICE ID DESCRIPTION -------- ---------------------------- 106 SEWER & WATER 301 ROUGH PLUMBING 507 FINAL PLUMBING REFERENCE NUMBER -------------------- VISA VOICE ID DESCRIPTION -------- ---------------------------- 202 UNDERFLOOR PLUMBING 400 SEWER/LATERAL CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: SUBCONTRACTOR PERMIT # Z, OWNER'S NAME: PHONE # GENERAL CONTRACT R: (,� e� BUSINESS LICENSE # ?6 , ADDRESS: 33qo 5 CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business ncense. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: Owner / Contractor Signature Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner / Contractor Signature Date CITY OF ( �C , J 2 - CITY OF CUPERTINO -lam REPIPE/SEWER/MAIN SERVICE CUPERTINO PERMIT APPLICATION FORM APN # Date: 113111 Fee Description Fee Group Building Address: 1()%3 5. Owner's Name: Mar Phone #: (40t) 25-3- Iq po Contractor: J 45W a' Phone #: Fax #: Contact: 3 39,0 y, Phone #: (` 001 S A - 040 Commercial re -pipe per fixture Fax/e-mail: Contractor License Cupertino Business License #: � Commercial Gas Piping System 1-4 Outlets Job Description: )k vt yo Residential N Commercial ❑ Valuation: 6, 015-D 1.-9 — B Project Size: Counter ❑ Express ❑ Standard 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. P Green Building Points: Quantity Fee ID Fee Description Fee Group Permit Type 1PCSEWER Commercial building sewer/sanitary sewer P 1CPSS 1BPREPIPE Commercial re -pipe per fixture P 1CPRP 1PGASCOM Commercial Gas Piping System 1-4 Outlets P 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICOM Seismic Commercial P Revised 12/06/10