B-2017-0062 CITY OF CUPERTINO BUILDING PE T
BUILDING ADDRESS: CONTRACTOR: P RMIT NO:B-2017-0062
10796 LINDA VISTA DR CUPERTINO,CA 95014-4021(356 08 003) AR S AMERICAN
RESIDENTIAL
SERVICES OF
CALIFORNIA INC
MEMPHIS,TN 38120
OWNER'S NAME: NELSON KELVIN R DTE ISSUED:01/11/2017
OWNER'S PHONE:408-252-9595 P.ONE NO:(901)271-9700
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT I 0:
License Class C-36:C-42 Lic.#765155
Contractor A R S AMERICAN RESIDENTIAL SERVICES OF CALIFORNIA INC X BLDG _ELECT X 'LUMB
Date 07/31/2018 _MECH X RESIDENT _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. REPLACE SEWER
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.
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: V:luation:$12000.00
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above APN Number: 0 cupancy Type:
information is correct.I agree to comply with all city and county ordinances 356 08 003
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 EXP I' S IF WORK IS NOT STARTED
City of Cupertino against liabilities,judgments,costs,and expenses which WITHIN 180 D YS OF PERMIT ISSUANCE OR
may accrue against said City in consequence of the granting of this permit.
Additionally,the applicant understands and will comply with .I-non-point 180 DAYS FRO i LAST CALLED INSPECTION.
source regulations per the -•= ino Municipal Code,S--'on 9.18.
Issued by:Abby Ayende
Signature Date 1/11/2017 Date:01/11/2017
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.rior to any roofing material being installed.If a roof is
following two reasons: installed without first obta'.'.g an inspection,I agree to remove all new materials for
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:1/11/2017
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 H• _•z IA u_T _ ■IS 9
performance of the work for which this permit is issued. I have read the hazardou materials requirements under Chapter 6.95 of the
2. I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Saf•ty 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 he Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,S•ction 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,sho Id 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 define by the Bay Area Air Quality Management District I
will maintain compliance ith the Cupertino Municipal Code,Chapter 9.12 and
Worker's Compensation laws of California. If,after making this certificate of the Health&Saf;ty ode,Sections 2 505,25533,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 age t
be deemed revoked. Date:1/11/2017
APPLICANT CERTIFICATION •b.. k
1 certify that I have read this application and state that the above information is I hereby affirm that there i-a construction lending agency for the performance
correct.1 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
AZoI -0(102-
1
•GENERAL PERMIT APPLICATION MEP
9,, COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISIO
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333•buildinq(a�cupertino.orq I S
❑PLUMBING ❑MECHANICAL ❑ELECTRICAL MISCELLANEOUS
PROJECT ADDRESS APN# �,, � +'
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OWNER NAME PHONE E-MAIL
STREET ADDRESS' T e CITY,STATE,Z FAX
CONTACT NAME t PHONE E-MAIL
kp\�, .Lg WIC( -9&z-o 3 f;7, Is tea.,c co q ts"cam,
STREET ADDRESS CITY,STATE,ZIP FAX
2())05— Cel.>;et I ® ,Tc CA-I ri 3)
o OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR 0 CONTRACTOR AGENT ❑ ARCHITECT 0 ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC#
COMPANY NAME ,gyp CA ( ,�.� ,, g
�..V 9�- �i��. J E MAH, •- �C✓tiJlSYlfnua € a us. FAX
STREET ADDRESS � CITY,STATE,ZIP nPHONE
QCA crck ,0 r . 5 `* CA 9 S li i 0krAz-camas'
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL
FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ' SFD or DUPLEX 0 MULTI-FAMILY PROJECT IN WILDLAND 0 YES PROJECT IN 0 YES IS THE BLDG AN ❑YES
,BUILDING: 0 COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
TOTAL VALUATION: 0 RECEIVED BY: O tIA l g E €J
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property oAIer's b a1f 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 relatin to building construc' . I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
r...1El-OVER-THE-COUNTER
0 EXPRESS
Li
' 0 STANDARD •
V
El LARGE
a
0 MAJOR
MEPMiscApp_2011.doc revised 06/21/11