B-2016-1686 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1686
10731 CASTINE AVE CUPERTINO,CA 95014-1347(326 43 037) A R S AMERICAN
RESIDENTIAL
SERVICES OF
CALIFORNIA INC
MEMPHIS,TN 38120
OWNER'SNAME: GOLDSWORTHY JON AND LINDA TRUSTEE DATE ISSUED:04/04/2016
OWNER'S PHONE:408-732-5190 PHONE NO:(901)271-9700
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-36 Lic.#765155
Contractor R S AMERICAN RESIDENTIAL SERVICES OF CALIFORNIA INC X BLDG —ELECT X PLUMB
Date 07/31/2016 MECH X RESIDENTIAL_COMMERCIAL
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 JOB DESCRIPTION:
license is in full force and effect. TWO WAY CLEAN OUT-FOUNDATION ONLY-PROPERTY LINE
CLEANOUT ALREADY IN PLACE
I hereby affirm under penalty of perjury one of the following two declarations: Rev#1-SEWER CLEAN OUT-FRONT YARD-ISSUED 4/29/16
1. 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: Valuation:$4500.00
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above APN Number: Occupancy Type:
information is correct.I agree to comply with all city and county ordinances 326 43 037
and state laws relating to building construction,and hereby authorize
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We)agree to save indemnify and keep harmless the PERMIT EXPIRES IF WORK IS NOT STARTED
City of Cupertino against liabilities,judgments,costs,and expenses which
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all,non-point 180 DAYS FROM LAST CALLED INSPECTION.
source regulations per the Cupertino Municipal Code,Section
Issued by:Abby Ayende
G;Signature Dat 44/29/2016 Date:04/04/2016
OWNER-BUILDER DECLARATION RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of the All roofs shall be inspected prior to any roofing material being installed.If a roof is
following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
t. I,as owner of the property,or my employees with wages as their sole inspection.
compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044,Business&Professions Code) Signature of Applicant:
2. I,as owner of the property,am exclusively contracting with licensed Date:4/29/2016
contractors to construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. 1 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 HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the
2. I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. I will
Section 3700 of the Labor Code,for the performance of the work for which this maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,Section 25532(x)should I store or handle hazardous.
3. I certify that in the performance ofthe work for which this permit is issued,.I material. Additionally,should.I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
Worker's Compensation laws of California. If,after making this certificate of the Health&Safety Code,Sections 25505,25533,and 25534.
exemption,I become subject to the Worker's Compensation provisions of the
Labor Code,I must forthwith comply with such provisions or this permit shag Owner or authorized agent:'
be deemed revolted. spate'4/29/2016
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
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
correct.I agree to comply with all city and county ordinances and state laws of work's for which this permit is issued(Sec.3097,Civ C.)
relating to building construction,and hereby authorize representatives of this city Lender's Name
to enter upon the above mentioned property for inspection purposes. (We)agree
to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Address
judgments,costs,and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally,the applicant understands ARCHITECT'S DECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal I understand my plans shall be used as public records.
Code,Section 9.18.
Licensed
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1686
10731 CASTINE AVE CUPERTINO,CA 95014-1347 A R S AMERICAN RESIDENTIAL SERVICES OF
(326 43 037) CALIFORNIA INC
2305 PARAGON DR.SAN JOSE,CA 95131
OWNER'S NAME: GOLDSWORTHY JON DATE ISSUED:04/04/2016
LINDA TRUSTEE
OWNER'S PHONE:408-732-5190 PHONE NO:408-982-0405
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class GENERAL ENGINEERING X_BLDG _ELECT XPLUMB
CONTRACTOR AM RICA 5 MECH X RESIDENTIAL_COMMERCIAL
Contractor R S AMERICAN RESIDENTIAL
SERVICES OF CALIFORNIA INC Date 07/31/2016
JOB DESCRIPTION: C_
o
I hereby affirm that I am licensed under the provisions TWO WAY CLEAN Cr rl- 1V"OATI ON ON Ly — e kQ f
of Chapter 9(commencing with Section 7000)of �►'�' :D
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:
L I have and will maintain a certificate of Sq.Ft Floor Area: Valuation:$4500.00
consent to self-insure for Worker's
Compensation,as provided for by Section APN Number: Occupancy Type:
370.0 of the Labor Code,for the performance 326 43 037
of the work for which this permit is issued.
z: I have and will maintain Worker's
1' Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the PERMIT EXPIRES IF WORK IS NOT STARTED
performance of the work for which this permit WITHIN 180 DAYS OF PERMIT ISSUANCE OR
is issued. 180 DAYS FROM LAST CALLED INSPECTION.
APPLICANT CERTIFICATION Issued by:Abby A ende
1 certify that I have read this application and
state that the above information is correct.I Date:04/04/2016
agree to comply with all city and county
ordinances and state laws relating to building RE-ROOFS:
Construction,and hereby authorize All roofs shall be inspected prior to any roofing material being installed.If a roof is installed without first obtaining an
representatives of this city to enter upon the
above mentioned property for inspection inspection,I agree to remove all new materials for inspection.
purposes. (We)agree to save indemnify and
keep harmless the City of Cupertino against Signature of Applicant:
liabilities,judgments,costs,and expenses Date:4/4/2016
which may accrue against said City in
consequence of the granting of this permit.
Additionally,the applicant understands and ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
will comply with all non-point source
regulations per the Cupertino Municipal Code, HAZARDOUS MATERIALS DISCLOSURE
Section 9.18. I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,
i) Sections 25505,25533,and 25534. I will maintain compliance with the Cupertino Municipal Code,Chapter
% ' 9.12 and the Health&Safety Code,Section 25532(a)should I store or handle hazardous material. Additionally,
Signatur should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air
Date 4/4/2016 Quality Management District I will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
the He th&Safety Code,Sections 25505,25533,and 25534. -
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Owner or authorized agent:
Contractor's License Law for one of the following two-Date:4/4/2016
reasons: CONSTRUCTIONLENDINGAGENCY
1. I,as owner of the property,or my employees I hereby affirm that there is a construction lending agency for the performance of work's for which this
with wages as their sole compensation,will do permit is issued,(Sec.3097,Civ C.)
Lender's Name
the work,and the structure is not intended or
offered for sale(Sec.7044,Business& Lender's Address
Professions Code)
i. I,as owner of the property,am exclusively
ARCHITECT'S DECLARATIO_N
contracting with licensed contractors to I understand my plans shall be used as public records,
construct the project(Sec.7044,Business&
Professions Code).
Licensed Professional
I hereby affirm under penalty of perjury one of the
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT o BUILDING DIVISION MEP
10300 TORRE AVENUE. CUPERTINO, CA 95014-3255
EJe EE fN (408)777-3228 a FAX(408)777-3333•building cupertino.ongMISC
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CONTRACTOR T-AI C,-Lk LICENSE]\Ulvj L/I `SE TYPE BUS.LI
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STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT 'WILDLAND ❑ YES PROJECTIN, ❑YES IS THE BLDG AN ❑YEs-
BUILD
ING: COA9�URCIAL URBAN INTERFACE AREA NO FLOOD ZONE 9
❑ I ❑ ❑NO EICHLERHO)`4E. ❑NO
DESCRIPTION OF WORK
TOTAL VALUATION:
By my signature below,I.certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the ption of'Work and verify it is accurate. I agree to comply with all applicable Iocal
ordinances and state laws relat g to build" nstruction. I an e retives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent:
Date: 4 lit,
SUPPLEMENTAL INFORMATION REQUIRED
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