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10030136 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10721 MORENGO DR CONTRACTOR:AMERICAN RESIDENTIAL PERMIT NO: 10030136 SERVICES OF CA NER'S NAME: KARL GERNER 965 RIDGE LAKE BLVD STE 201 DATE ISSUED:03/23/2010 OWNER'S PHONE: 4082181883 MEMPHIS,TN 38120 PHONE NO:(408)982-0405 ❑ LICENSED CONTRACTOR'S DECLARATIONyRTION BUILDING PERMIT INFO: BLDG ELECT r PLUMB r License Class C-_ Lic.# +(OS-/._�� MECH RESIDENTIAL COMMERCIAL _J-2-3J0 � Contractor S�J�.�UC1� Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:INSTALLING BUILDING CLEANOUT REPLACING WATER (commencing with Section 7000)of Division 3 of the Business&Professions SUPPLY FROM METER TO HOME 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 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 Sq.Ft Floor Area: ati $5800 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:37534019.00 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 to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF W K IS NOT STARTED upon the above mentioned perty for inspection purposes. (We)agree to save indemnify and keep h ess he City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses ich y accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. granting of this p it. Ad itionally,the applicant understands and will comply with all non-po' t source r gulations per the Cupertino Municipal Code,Section 9.18. J Issued by: Date: i ature Date ��•2 / +i ❑ OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. 1,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: i Date: Business&Professions Code) 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 HAZARDOUS MATERIALS DISCLOSURE declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I 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 contaminants defined by the Bay Area Air Quality Management District I will permit is issued. maintain mpli ce with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall Healt Safety ode,Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's il Compensation laws of California. If,after making this certificate of exemption,I Ow er or authorized agent: become subject to the Worker's Compensation provisions of the Labor Code,I must Date: ((/ forthwith comply with such provisions or this permit shall be deemed revoked. I- '�STRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter the above mentioned for inspection purposes.(We)agree to save Lender's Address unify and keep h ess the ity of Cupertino against liabilities,judgments, costs,and expense hich may crue against said City in consequence of the ARCHITECT'S DECLARATION granting of this rmit.Additio ally,the applicant understands and will comply with all non-p nt source regu tions per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signature Date JJ CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 37534019 . 00 DATE ISSUED. . . . . . . : 03/23/2010 RECEIPT # . . . . . . . . . BS000010004 REFERENCE ID # . . . : 10030136 SITE ADDRESS 10721 MORENGO DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER KARL GERNER ADDRESS 10721 MORENGO DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : AMER RES SVCS LLC 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 5, 800 . 00 1. 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 5, 800 . 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 #8128005168 --------------- 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 REPIPE/SEWER/MAIN SERVICE CUPEkTINO PERMIT APPLICATION FORM APN# Dt. cl Building--Address: i o -,O-Y\ ` Owner's Name: Phone#: CW I GE'er' \,I o C tractor: Phone#: C-1 o? cig-z -c-- c6 -P-S C-.1'Q_ Fax#: Contact: vnpr Phone#: q --�`1Ll , Fax#: Contractor License#: SS Cupertino Business License#: 2l SU L Job Description: CJ1L� Residential Commercial ❑ Valuation;,, STai aluation , a. Project Size: ExpressEl 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. 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 1 PGASCOM Commercial Gas Piping System P 1-4 Outlets 1 BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES 1 BSEISMICOM Seismic Commercial P Revised 01/07/09 CITY OF CUPERTINO REPIPE/SEWER/MAIN SERVICE CUPEkTiNO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group 1BCBSC Cal Bldg Standards Commission B ALL PERMIT I> Fee TYPES 1BSEISMICR Seismic Residential P 1 PRSEWER Residential building P 1RPSS sewer/sanitary sewer 1 PRREPIPE Residential re-pipe per fixture P 1RPRP 1BPWSVCS Water Service P 1CPWS or 1RPWS 1PPRSEWG Private Sewage Disposal System P 1PCESS Cesspool P 1 BPWATER Install/alter Water Pipe P 1 BPFIXTURE Plumbing Fixture P 1 PGASRES Residential Gas Piping System P 1-4 Outlets 1BPGAS Gas Piping System 5+ Outlets P / 1 PPERMITFEE Plumbing Permit Fee Issuance P / 1 PLMBLNCK Plumbing Plan Check P 1PLMBINSP Other Plumbing/gas Insp. P 1 TRAVDOC Travel & Documentation Fee B 1BUSLIC Business License B Building Department City Of Cupertino 10300 Torre Avenue Cupertino,CA 95014-3255 Telephone: 408-777-3228 CUPERTINO Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: lQ 2 PERMIT# 1 OWNER'S NAME: 2✓ PHONE# GENERAL CONTRACTOR: �Lc'-Ire� BUSINESS LICENSE # ADDRESS: CITY/ZIPCODE: *Our municipal code requires all businesses workirfg in he 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 SVIRCON RACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and comp the followin infor 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