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10090222 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21597 ROSARIO AVE CONTRACTOR:AMERICAN RESIDENTIAL PERMIT NO: 10090222 SERVICES OF CA r `PER'S NAME: RICHARD PEREZ 965 RIDGE LAKE BLVD STE 201 DATE ISSUED:09/23/2010 OWNER'S PHONE: 4084464180 MEMPHIS,TN 38120 PHONE NO:(408)982-0405 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# - � MECH r— RESIDENTIAL r COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:WATER HEATER INSTALLATION (commencing with Section 7000)of Division 3 of the Business&Professions 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. Sq.Ft Floor Area: Valuation:$1690 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 permit is issued. X"12— APN Number:35619032.00 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building constriction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply J� with all non-point source regulations per the Cupertino Municipal Code,Section Issued by; Date, , 9.18. 11 Ir iture4g, Date v RE-ROOFS: ❑ OWNER-BUILDER DECLARATION 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 I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the p Health&Safety Code,Sections 25505,25533,and 25534. 1 certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the Worker's On ,or authored agent•Compensation laws of California. If,after making this certificate of exemption,I ! il�� become subject to the Worker's Compensation provisions of the Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name correct.I agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize representatives of this city to enter Lender's Address the above mentioned property for inspection purposes.(We)agree to save anify and k harmless the Ci of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 5 ITEMS OF 5 PERMI" RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: B1}:. Lot: APN . . . . . . . . : 35619032 .00 DATE ISSUED. . . . . . . : 09,'23/2010 RECEIPT 4. . . . . . . . . : BS000011538 REFERENCE ID # . . . : 10090222 SITE ADDRESS . . . . . : 21597 ROSARIO AVE SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : RICHARD PEREZ ADDRESS . . . . . . . . . . : 21597 ROSARIO AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : AM]-',RICAN RESIDENTIA CONTRACTOR . . . . . . . : DONALD KARNES LIC # 21504 COMPANY . . . . . . . . . . : AMHRICAN 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 1, 690. 00 1.00 0 .00 1. 00 0 .00 1BSEISMICR VALUATION 1, 690 .00 0 .50 0 .00 0 .50 0 .00 1PPERMITFE FLAT RATE 1. 00 42 .00 0. 00 42 . 00 0 . 00 1PRWHEATR UNITS 1. 00 25 .00 0. 00 25. 00 0 . 00 1TRAVDOC FLAT RATE 1. 00 42 .00 0. 00 42 . 00 0 . 00 - --------- ---------- ---------- ---------- TOTAL PERMIT 110 .50 0. 00 110 .50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 110 .50 #8128005363 --------------- TOTAL RECEIPT 110 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 518 WATER HEATER CITY OF CUPERTINO WATER HEATER CUPERTINO PERMIT APPLICATION FORM APN # -� Date: Building Address: Owner's Name: Phone #: R 0,64cb Contractor: Phone #: 126s�u&7;" - t2-0vFax #: Cupertino Business License #: -1 J'°�� Contractor State License #: Contact: Phone #: Fax #: Building Permit Info: Bldg Elect �-, / Plumb Mech Residential Commercial ❑ Job Description: JOR Strapped On Platform ❑ Bonded New Location ❑ Replacement Valuation (cost of project): �< Project Size: Express ❑ StandardV 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 achieved: Revised 03/10/10 CITY OF CUPERTINO FEE ESTIMATOR-- BUILDING DIVISION ADDRESS: DATE: REVIEWED BY: APN: BP#: *VALUATION: 1$1,600 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY 1 PENTAMATION PRWHEATR USE: SFD or Duplex I rl)t�)dti .i� �r PERMIT TYPE: WORK SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Water Heater 1 PRWHEATR 1 # $25 TOTALS: $25.00 -T-1 a�<<rr F'tExrr c Ftc'r . Plumb.Plan Check 0.07 hrs $0.00 Plumb.Permit Fee: IPPERMIT VIC( t',.r,,Ni 1" Other Plumbr Inst. 0.0 hrs $42.00 1W NOTE. Theseees are based on the preliminary in ormation,mailable and are only an estimate. Contact the De t or addn'l info. FEE ITEMS (Fee Resolution 09-05/ Ef'. T'1%1 n) FEE QTY/FEE MISC ITEMS .Sujf7/. I'C.. t`t::E:' PME Plan Check: $0.00 1'elirlit F<>er PME Unit Fee: $25.00 PME Permit Fee: $42.00 ("oll";1niclion Tax Rcvicw Work Without Permit? 0 Yes No $10.00 l'1C7i71t177�y l`c'E', ." Travel Documentation Fee: ITRAVDOC $42.00 A Strong Motion Fee: $).50 Select an Administrative Item Bldg;Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $11 ).50 $0.00 TOTAL FEE: $110.50 Revised: 9/22/2010 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: t% 4 '1 �`' S c' s. '.� PERMIT# d d ZZ�L OWNER'S NAME: PHONE# GENERAL CONTRACTOR: BUSINESS LICENSE# ? r ADDRESS: CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPPERTINO BUSINESS LICENSE. /' L�c��G"f� � // I am not using any subcontractors: S gnature Date Please check applicable subcontractors and complete the following information: V 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 lumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date