B-2016-2993CITY OF CUPERTINO BUILDING PERMIT
BUILDING
10380
ADDRESS:
RIVIERA RD CUPERTINO, CA 95014-2743
CONTRACTOR:
PERMIT NO: B-2016-2993.
(357 08 042)
A R S AMERICAN
RESIDENTIAL
SERVICES OF
CALIFORNIA INC
i
MEMPHIS, TN 38120
OWNER'S NAME: ZUO JEAN J
DATE ISSUED: 10/26/2016
OWNER'S PHONE: 650-417-8657
PHONE NO: (901) 271-9700
iICEpNSED CONTR TOR' DECLARATION
BUILDING PERMIT INFO:
License Class C-36: C -42A Lic. #765155
ContractorA R S AMERICAN RESIDENTIAL SERVICES OF_CALIFORNIA IN
X BLDG ELECT X PLUMB
Date 07/31 /2018
{I
_
_ 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.
It
REPLACE BUILDING SEWER; TWO WAY CLEAN OUT
I hereby affirm under penalty of perjury one of the following two declarations:
L 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.
pp 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: $2900.00
permit is issued.
APPLICANT CERTMCATION
certify that I have read this application and state that the above
APN Number:
Occupancy Type:
mformt ation is correct. I agree to comply with all city and county ordinances
357 08 042
and sate 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 1$0 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: Abby Aygnde
S" ignature Date 10/26/2016
Date: 10/26/2016
O R -B iR D R DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RE -ROOFS:
All roofs shall be inspected nor to an roofing material being installed. If a roof is
P prior Y g g
following two reasons:
installed without first obtaining an inspection, I agree to remove all new materials for
i'. 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: 10/26/2016
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
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
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
permit is issued.
Health & Safety Code, Section 25532(a) should I store or handle hazardous
3 1 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:
10/26/2016
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
I cerci y 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.)
relatir g to building construction, and hereby authorize representatives of this city
Lender's Name
to ent 3r 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
ARCHITECT'S DECLARATION
consequence of the granting of this permit. Additionally, the applicant understands
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
^ ^ Z 642)
GENERAL PERMIT APPLICATION IRANE
P
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 build ing(cDcu pertino.org misc
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PROJECT ADDRESS _
f ( � 2 APN# 67- OP?
0ER NAME E-MAIL
� PHONE
STET ADDRE( 03 11,-0 I C Y, STAT Fly
CONTACT NAME
LSTREE
PHONEE V i.S,_,a(T ADDRESS n TY, STATEP FAX
❑
OWNER ❑ OWNER -BUILDER ❑.OWNER AGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGWEER ❑ DEVELOPER 11 TENANT
CO
TRACTOR N LICENSE NUMBER LICENSE TYPE BUS. LTC
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COMPANY NAME _ 19 _ _ _ I: 3 E-MAIL�� e FAX /
ST�'EET ADDRESS
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ARCHITECT/ENGINEER NAME
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LICENSE NUMBER
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BUS. LIC #
C07ANY NAME
E-MAIL
FAX
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STI i ET ADDRESS
CITY, STATE, ZIP
PHONE
USE"1.OF SFD or DUPLEX ❑ MULTIFAMILYPROJECT
IN WIIALAND ❑ YES
PROJECT IN ❑YES
IS THE BLDG AN El YES
BUILDING: ❑ COMMERCIAL
URBAN INTERFACE AREA ❑ NO
FLOOD ZONE ❑ NO
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK 1 _
_ I
TOTAL VALUATION, t;RVNED
-Cloo'.,
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 Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building c nstruction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
SiRatureofApplicant/Agent. Date:���
SUPPLEMENTAL INFORMATION REQUIRED
OFFICE [ISE ()NL Y` ."
MEPMiscApp_2011.doc revised 06121111