B-2016-2199 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2199
20126 MERRITT DR CUPERTINO,CA 95014-2011(316 33 103) A R S AMERICAN
RESIDENTIAL
SERVICES OF
CALIFORNIA INC
MEMPHIS,TN 38120
OWNER'S NAME: TALLINGER GERALD G AND BEVERLY M 71 RUSTEE DATE ISSUED:06/23/2016
OWNER'S PHONE:408-829-0645 PHONE NO:(901)271-9700
LICENSED CONTRACTOR'S DECLARATION BUILDING PEP-NUT INFO:
License Class GENERAL ENGINEERING CONTRACTOR Lic.#765155 X BLDG —ELECT X PLUMB
Contractor A R S AMERICAN RESIDENTIAL SERVICES OF CALIFORNIA INC —
Date 07/31/2018 _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 CLEAN OUT;NEW FOUNDATION CLEAN OUT AND
PROPERTY LINE CLEAN OUT
I hereby affirm under penalty of perjury one of the following two declarations:
r. I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labo Code,for the
J n 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 Nork for which this Sq.Ft Floor Area: Valuation:$11452.00
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 o dinances 31633 103
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 ha�Ies
mless the PERMIT EXPIRES IF WORK IS NOT STARTED
City of Cupertino against liabilities,judgments,costs,and expert which WITHIN 180 DAYS OF PERMIT ISSUANCE OR
may accrue against said City in consequence of the granting of t,his permit.
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 9. 8.
Issued by:Abby Ayende
Signature Date L231 016Date:06/23/2016
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
1. I,as owner of the property,or my employees with wages as Leir sole inspection.
compensation,will do the work,and the structure is not miteed or offered for
sale(Sec.7044,Business&Professions Code) Signature of Applicant:
2. I,as owner of the property,am exclusively contracting with icensed Date:6/23/2016
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. I have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Laboi 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 vork for which this maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,Section 25532(a)should I store or handle hazardous
3. I certify that in the performance of the 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 ubject 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 makin this certificate of the Health&Safety Code,Sections 25505,25533,and 25534.
exemption,I become subject to the Worker's Compensation rovisions of the
Labor Code,I must forthwith comply with such provisions or this permit shall Owner or authorized agent:
be deemed revoked. Date:6/23/2016
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,to 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 Cup'rtino Municipal I understand my plans shall be used as public records.
Code,Section 9.18.
Licensed
GENERAL PERMIT APPLICATION , ,.
E P
COMMUNITY DEVELOPM NT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE-
UPERTINO, CA 95014-3255 W(408)777-3228• FAX(408 777-3333• buildincl(o)cupertino.orct � ^
CUPERTIRIO
PLUMBING EIMECHANICAL [:]ELECTRICAL MISCELLANEOUS
PROJECT?DDRESS2(=>j2-(o � , APN rL A�- 1®3
O\VNERNAA F PHONTE �J 6 J'E--MAIL
er G.11 I 0 a K-
STREET ADDRESS Zr,�� CITY, STATE,ZIP �� 1 Q^ Cj`O+� FAX
V`t ;
CONTACT NAME Q�iNV\ PHONE 41
- �� � E-MAIL
STREETADDRESS �� CTTY,�TATE,Z FAX
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❑ ORRdER ❑ OWN'ER.BUILDER ❑ OwN'ERAGENT ❑ CON![RACTOR ❑CONTTRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TEN_A1.T
CONTRACTOR NAME LICENSENUMB(9 S1 5'S l:C '�O C-L(.Z n BUS.LICn
COMPANY NAME E-MAIL (/ ,T FAX
STREET ADDRES5CITY,STATE;ZIP 36 � 2 PHONE
o�
N _^&-Z
ARCHITECT/EGIN'EER NAME iICENSE NUMBER ) BUS.LIC.1 +
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD.,DUPLEX ❑ MULTI-FAMILY PROJECT IN N'ILDLAND ❑ YES PROJECT 114 ❑YES I IS THE BLDG AN ❑ YES
BUILDLNG: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO .FLOOD ZONE ❑NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
C�AA
'C...e
TOTAL VALUATION:
By my signature below,1.certify to each of the following: I am the property owner or authorized agent to act on the property owner's b half. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relay g to building construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/AQent ( Date: Co"
SUPPLEMENTAL INIFORA4ATION REQUIRED
a O ER TAE COUNTER ,°>
4
4
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STANDARD t t
W.U y
MEPAl scApp_201].doe revised 06/21/11
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