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B-2017-0139 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0139 10650 CASTINE AVE CUPERTINO,CA 95014-1313(326 43 030) ARS AMERICAN RESIDENTIAL SERVICES OF CALIFORNIA INC MEMPHIS,TN 38120 OWNER'S NAME: NJEH TAI-GANG AND CHANG CHIEN-I DATE ISSUED:01/25/2017 OWNER'S PHONE:408-3864547 PHONE NO:(901)271-9700 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class C36.C42 Lic.#7651_55 ContractorA R S AMERICANRESIDENTIAL 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. REPLACE 50 GAL WATER HEATER-GARAGE I hereby affirm under penalty of perjury one of the following two declarations: 11 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 P.91formance of the work for which this permit is issued. 0 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:$2834.00 'permit is issued. APPLICANT CERTIFICATION APN Number: Occupancy Type: I certify that I have read this application and state that the above 32643030 information is correct.I agree to comply with all city and county ordinances 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 17 WORK IS NOT STARTED C4 of Cupertino against liabilities,judgments,costs,and expenses which WITHIN 180 DAYS 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 all non-point 180 DAYS FROM LA CTION. source regulatio,ns per the Cupertino Municipal Code,Section 9.18. Issued by:MELIS L�ZM_ Signature Date 01/25/2017 Date:01/25_/_2_0_17 �77 OWNER 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 now materials for 1. 1 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. L as owner of the property,am exclusively contracting with licensed Date:01/2512017 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. 1 have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. 1 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&Safety Code,Section 25532(a)should I store or handle hazardous permit is issued. material.Additionally,should I use equipment or devices which emit hazardous 3. 1 certify that in the performance of the work for which this permit is issued,I air contaminants as defined by the Bay Area Air Quality Management District I shall not employ any person in any manner so as to become subject to the 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 255Q5,25533,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:01/25/2017 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 Lender's Address to save indemnify and keep harmless the City of Cupertino against liabilities, judgments,costs,and expenses which may accrue against said City in ARC=CT'S DECLARAUDN 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 I GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO, CA 95014-3255 A9911L AdWkL (408)777-3228- FAX(408)777-3333-buildinc(lcupertino,orq CUPERTINO m I t3 0,0 1*73- ;�2 El PLlJ'T'N4BrNC' OMECHANICAL El ELECTRJCAL EIMISCELLANEOUS PROJECT ADDRESS '4-tAJL APN# �3 Z q a O'NMR NAME � "" " I "ONE k1ro '�C_-2, m Ile L+ STREET ADDRESS CITY, I'Qk5-o' I S= FAX C SZ I 1'q' I CONTACT NAM -MAIL E Tpr IS A t _10q0 STREET ADD ,, rl CITY,STATE,ZIP FAX LA Ln� 'Zg C'q- L-3 ❑ OWNER El OWNER-BUILDER 171 OWINTERAGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT 11 ENGINEER 171 DEVELOPER 11 TENANT CONTRACTOR NAME LICENSE Nt ER LINSEP BUS.LIC'­7 AJ99, COMPANYNAVIE STREET DRESS Cg,�T TE,Z afoL!�� i, (:�IP 11ON 0 1 -_2 ARCI]ITECT/ENG11*\TEER.NAME LICENSE NUMBER BUS.LIC# CONIPANTY NAME E-MAIL FAX STREET-ADDRESS CITY,STATE,ZIP PHONE USE OF O.SFD.,DUPLEX 11 MULTI-F.A-MMY PROJECT I\'V+`ILDLAJ\D ❑ YES PROJECT IN 0 YES IS THE BLDG AN El YES BUH-DING: []COMMERCLkI, URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLERHOME? ❑NO DESCRIPTION OF woRK 3`0 0�0,A _0604-,r V, _�)r 7' TOTAL VALUATION: Z_ REEiV _3 By my signature below,I certify to each ofthe following: I am the property owner or authorized agent to act on the property owner:Z-�. 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 xelatina to building construction authorize representatives of Cupertino to enter the above-identified property for inspectionpurposes. Signature ofApplicant/Agent: Date: 1,z- Ut77 SUPPLEMENTAL INFORMATION REQUIRED OVER THE-COU'STER. "K 5i© EGRESS '-i ARG A2EPA,flscApp__2011.doc revised 06121111