B-2016-2935 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2935
18800 LOREE AVE CUPERTINO,CA 95014-3635(375 15 022) ARS AMERICAN
RESIDENTIAL
SERVICES OF
CALIFORNIA INC
MEMPHIS,TN 38120
OWNER'S NAME: ZHANG YE AND WU YICHING DATE ISSUED:10/18/2016
OWNER'S PHONE:408-982-0405 PHONE NO:(901)271-9700
LICENSED CONTRACIOR'S CONTRACTOR'SDECLAR&TION BUILDING PERMIT INFO:
License Class C3 Lic.#765155
Contractor R S AMERICAN RESIDENTIAL SERVICES OF CALIFORNIA INC X BLDG _ELECT X PLUMB
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. CLEANOUT BUILDING SEWER 2 WAY
I hereby affirm under penalty of perjury one of the following two declarations:
i. 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.
2. I have and will maintain Worker's Compensation Insurance,as provided for by
f Section 3700 of the Labor Code,for the performance of the work for which this
Sq.Ft Floor Area: Valuation:$2643.00
permit is issued.
APPLICANT CERTIFICATION
I certify that t 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 375 15 022
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 9.18.
Issued by:Kim Dunbar
Signature mate 10-18-2016 Date:10/18/2016
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 i0�.;
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 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:10-18-2016
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
n. 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 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. 1 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
Health&Safe Code,Section 25532 a should I store or handle hazardous
permit is issued. Safety ( )
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 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 shall Owner or authorized agent
be deemed revoked. Date:10-18-2016
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
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION MEP
10.300 TORRE AVENUE•CUPERTI NO,CA 95014-3255
(408)777-3228•FAX(408)777-3333 buildinCUPERTINOg(d)cupertino.org misc
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❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS APN#
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❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME � LICENSE NUMBER / LICENSE TYPE id 2 BUS.LIC#
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ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
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STREET ADDRESS CITY,STATE,ZIP
PHONE
USE OF USE orDUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
TOTAL VALUATI26 AEC DBIz'"
By my signature below,I certify to each of the following: I am the property owner or authorized agent o act 94 tfe property owner's behalf 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 rel * g to building con Io . I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature ofApplicant/Agen Date:
SUPPLEMENTAL INFORMATION REQUIRED °h OMC- bSr y
oYERTIIECO.(Jt�TER""
❑"'EXPRESS .
❑"STANDARD
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MEPMiscApp_201 Z doc revised 06121111