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10030082 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 18856 HUNTER WAY CONTRACTOR:AMERICAN RESIDENTIAL PERMIT NO: 10030082 SERVICES OF CA C'-VNER'S NAME: MANISH PANJIAR 965 RIDGE LAKE BLVD STE 201 DATE ISSUED:03/15/2010 NER'S PHONE: 6507995624 MEMPHIS,TN 38120 PHONE NO:(408)982-0405 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG I- ELECT f- PLUMB License ClassC-3(,O Lic.�#p /Z MECH F RESIDENTIAL r COMMERCIAL Contractor Tl:. �Ld ,"� Date '/ JOB DESCRIPTION: SEWER LINE REPLACEMENT I hereby affirm that I am licensed under the provisions of Chapter 9 (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 .4 . Aftip 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: lu n. 000 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. APN Number:37535063.01 c ancy 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 EXPIRESI FWORK IS NOT STARTED to building construction,and hereby authorize representatives this city enter WITHIN 180 DA'`�$"OF PERMIT ISSUANCE OR upon the above mentioned property for inspection purposes. (We)agree too save indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs,and expense i may accrue against said City in consequence of the granting of this p rm, t. diditionally,the applicant understands and will comply with all non-poitit sour a regulations per the Cupertino Municipal Code,Section Issued by Date: 9.18. 3-/ Siqnature 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 maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Health ale de,Sections 25505,25533,and 25534. I 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 O�=orautl ed agent: t-� _ fy-� 76 Compensation laws of California. If,after making this certificate of exemption,I Date:— become /� `l 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 v, -the above mentioned property for inspection purposes.(We)agree to save inify and keep h ess the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION .5,and expense hich the accrue against said City in consequence of the granting of this p it.A itionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-poi source egulations per the Cupertino Municipal Code,Section 9.18. / Licensed Professional Signature \_ Date �S'/Q J CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 37535063 . 01 DATE ISSUED. . . . . . . : 03/15/2010 RECEIPT #. . . . . . . . . BS000009939 REFERENCE ID # . . . : 10030082 SITE ADDRESS 18856 HUNTER WAY SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER MANISH PANJIAR ADDRESS 18856 HUNTER WAY 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 ---------- ------------- ---------- ---------- -------- 1BCBSC VALUATION 6, 000 . 00 1 . 00 0 .00 1. 00 0 . 00 1BSEISMICR VALUATION 6, 000 . 00 0 . 60 0 . 00 0 .60 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 .60 0 . 00 106 . 60 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------- CHECK 106 . 60 #8128005164 --------------- TOTAL RECEIPT 106 .60 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- -- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 507 FINAL PLUMBING CITY OF CUPERTINO J �' -,a0i REPIPE/SEWER/MAIN SERVICE CUPE�TINO PERMIT APPLICATION FORM Building Address: scz-) u- Owner's Name: Phone#: YVlaw� ; Contractor: Phone#: 110$-'s-9 �- �,� eS CJ e Fax #: Contact: Phone#: Sa VVA-r- 'Amf )Yl &� U Fax#: Contractor License#: '2tSo,,-,t Cupertino Business License#: Job Description: S � ��„Q fly Residential Commercial ❑ Valuation` Project Size: Express StandardO, Large Major El 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 1BPREPIPE Commercial re-pipe per fixture P 1CPRP 1PGASCOM Commercial Gas Piping System P 1-4 Outlets 1BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES 1BSEISMICOM Seismic Commercial P Revised 01/07/09 CITY OF CUPERTINO REPIPE/SEWERJMAIN SERVICE CUPEkTINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group 1BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES 1BSEISMICR Seismic Residential P // 1PRSEWER Residential building P IRPSS isewer/sanitary sewer 1 PRREPIPE Residential re-pipe per fixture P 1RPRP 1BPWSVCS Water Service P ICPWS or 1RPWS 1PPRSEWG Private Sewage Disposal System P 1 PCESS Cesspool P 1BPWATER Install/alter Water Pipe P 1 BPFIXTURE Plumbing Fixture P 1PGASRES Residential Gas Piping System P 1-4 Outlets 1BPGAS Gas Piping System 5+ Outlets P 1 PPERMITFEE Plumbing Permit Fee Issuance P 1PLMBLNCK Plumbing Plan Check P 1PLMBINSP Other Plumbing/gas Insp. P 1TRAVDOC Travel & Documentation Fee B 1BUSLIC Business License B Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 Fax(408)777-3333 CITY OF CUPEkTINO Buj1d, De artment ,::JOB ADDRESS: PERMIT # OWNER'S NAME: PHONE # qQe6 -Sc GENERAL CONTRACTOR es c<; ?r-� FAX # I am not using any subcontractors: Signa Date Please check applicable subcontractors and cornTete the followin information: =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 Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date