B-2017-1806 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1806
10382 SCENIC CIR CUPERTINO,CA 95014-2766(357 07 024) A R S AMERICAN .
• RESIDENTIAL
SERVICES OF '
' CALIFORNIA INC
MEMPHIS,TN 38120
OWNER'S NAME: GUHATHAKURTA SANJIB AND RAY MALINI DATE ISSUED: 10/20/2017
OWNER'S PHONE:408-307-2853 PHONE NO:(408)283-9536
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class.C-20 Lic.#742039
Contractor A R S AMERICAN RESIDENTIAL SERVICES OF CALIFORNIA INC X BLDG _ELECT _PLUMB
Date 10/31/2019 X 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 FURNACE SAME LOCATION;REPLACE AC UNIT SAME
LOCATION
I hereby affirm under penalty of perjury one of the following two declarations:
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 Labor Code,for the
of the work for which this permit is issued.
,erformance
have and will maintain Worker's Compensation Insurance,as provided for by
ection 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: Valuation:$12000.00
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 ordinances 357 07 024
and state laws relating to building construction,and hereby authorize
representatives df 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 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
may accrue against said City in cdnsequence of the granting of this permit.
Additionally,(he applicant understands and will comply with all non-point 180 DAYS FROM LAST CALLED INSPECTION:
source regulations etfhe upertino Municipal Code,Section 9.18.
,, .�.t Issued by:Kim Dunbar
Signatu�et ✓✓��'�, Nw s 0" L,04iL,i Date 10-20-2017 • .Date: 10/20/2017- •
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 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
t. 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: 10-20-2017
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
•
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 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. 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 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. 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,Ch: ter 9.12 and
Worker's Compensation laws of California. If,after making this certificate of the Health&Safety Crde,Sect'i., - 505,255 d 25 r34.
exemption,I become subject to the Worker's Compensation provisions of the _ fl
-I
Labor Code,I must forthwith comply with such provisions or this permit shall 1 Owner or authorized age ;;,' Mt .1,11
be deemed revoked. Date:10-20-2017
APPLICANT CERTIFICATION CONSTR?CTION 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
•
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
rig0 n 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 •
�Sf l-r ,.. • -2-011-
- !1— - V 1J Vl
(408) 777-3228 • buil PEMIT#B-
CUPERTINO REV# DEFe
❑ NEW CONSTRUCTION ❑ADDITION N ALTERATION ❑1".1. ❑MEP ❑RE-ROOF ❑SWIMMIN/G/POOL/SPA
PROJECT ADDRESS i` CeVk 1• c C`4,' APN r ', -0 I _
OWNER NAME •,..,q..
� II \ ( q I ll PHONE��o ) 367 z ps E-MAIL
STREET ADDRESS V �•J 1ZN) VI LI I Y, STATE,ZIP
1( ? 7_ S CeNA (_ Of Lip ecl-: :v,0 I CAI Sc!) t 1-
D CONTRACTOR NAME 0 OWNER-BUILDER COMPANY NAME LICENE NUMBER LICENSE TYPE
A.Nks .."-c,,:‘61)%4 1)%4 AnS 1'zo3 t C—2 0
ISTREETADDRESS Z3O5 es C-L- Ov\a pc CITY,STATE, ZIP V\ ®c� ) 0�, 5 SY ) I
E-MAIL PHONE J BUS.LIC p
,rec ��s. coyer L'�3) 272— i S6.
0 ARCHITECT 0 OWNER.❑OWNER AGENT 0 CONTRACTOR AGENT 0 ENGINEER❑DEVELOPER 0 TENANT
• CONTACT NAME E-MAIL'
STREET ADDRESS CITY,STATE,ZIP PHONE
DECRIPTON
e_11��y,•.e c,� ``- o q AcnA s`. c
Stce cvr vIc,,c4 A c , -
Com evi.,er 0v11JCO► r 1,)1,2_ '‘ l;\lk 4.,i,i_. 1 oCcL\idv\
7SINGLE-FAMILY/DUPLEX '0 MULTI-FAMILY 0 INDUSTRIAL 0 COMMERCIAL I
EXISTING/ USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES I TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION(5)
REMODEL REMODEL KITCHEN REMODELOTHR GARAGE 0 ATTACHED ,
BATHROOM SF ,SF SF SF 0 DETACHED
•
EXISING DYES EICHLER ❑ YES SECOND STORY ADDITION ❑YES
FIRE SPRINKLERS 0 NO 0 NO 0 NO
DWELLING SECOND DWELLING ❑YES 0 ATTACHED 0 DETACHED OTHER
UNITS a UNIT ADDITON: ❑NO S F
POOLS 0 FIBERGLASS 0 VINYL-LINED 0 GUNITE 0 PREFABRICATED
POOL-SF SPA-SF I SPA ATTACHED❑YES 0 NO l TOTAL-SF . ' ,
RECEIV Y: TOT VI DATION:
Commercial or Multi-Family Buildings with Public Swimming Pools respires Department of Environmental Heath anaronal �� I210110 . a®
RE-ROOF EXISTING ROOF TYPE: ❑BUILT-UP ROOF❑ASPHALT SHINGLES❑WOOD SHAKES❑WOOD SHINGLES❑TILE OTHER(SPECIFY) •
REMOVE/REPLACE❑NO IF NO PLYWOOD ❑15" ❑3/8" PLYWOOD TYPE: PITCH: ROOF CLASS
DYES 1 OF LAYERS THICKNESS❑5/8" OTHER ❑OSS ❑CDX OTHER •12 A
PROPOSED ROOF TYPE:❑BUILT-UP ROOF DASPHALT SHINGLES 0 WOOD SHAKES❑WOOD SHINGLES 0 OTHER'1'
*Provide a signed copy of the Cupertino's Tear-Off Policy SF tof SQUARES
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 re .ting to building construction. I authorize representatives of Cupertino to
enter the above-identified property for inspection purpu s. I ac iowledge and authorize all information contained on this application form
to be made available for public record. in
� 'I , ,O` Zo�l7
" Signature of Applicant/Agent: a•gr_l'i± iy„ I Date: II
•
SUPPLEMENTAL INFORMATION REQUIRED F
*New SFD/Second Dwelling Units/Multifamily Dwellings:A Demolition permit is required prior to issuance of a building permit for all new construction. •
*Commercial Buildings: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project.
*Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application.
*HOA-Provide a letter of approval from the Home Owner's Association
•
BldgApp_2017.doc revised 08/01/17
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Agent Authorization for Contractor
Company/Contractor's Name: ARS/American Residential Services of California Inc.
dba Atlas Trillo
Contractor's License Number:742039
Email:sparrish@ars.com
The below listed individual employee(s)are authorized to apply to all city and county agencies for a
building permit and licenses on behalf of the above identified licensed contractor. I understand that it is
the licensed contractor's responsibility to provide a copy of this form with each building permit
application. If a copy'of this form is not provided at the time that a building permit application is filed,an
agent(s)of the above identified licensed contractor may not apply for a building permit.
The below listed employees are authorized to apply for permits for the above identified licensed
contractor:
Print Name(s)of authorized employees:
1.Harry Chi 0 2.LauraJohnson
3.CharlesShaw ' 4.JamesMichie
5.RobCleaver 6. DaveSmith
7.Tim Lane 8. KyleKilby
9.Kyle Au Coin ' ' 10.Kim Foster
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