B-2018-0566 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO;B-2018-0566
20791 SCOFIELD DR CUPERTINO,CA 95014-2922(359 12 004) A R S AMERICAN
RESIDENTIAL
SERVICES OF
CALIFORNIA INC
MEMPHIS,IN
38120
OWNER'S NAME: DATE ISSUED:04/06/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C_20 Lic.#742039
Contractor R SAMERICAN 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
ADD AC UNIT-LEFT SIDE OF HOUSE
1 he
reby affirm under penalty of perjury one of the following two declarations:
and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work far which this Sq.Ft Floor Area: Valuation:$0.00
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above APN Number: Occupnncy Typr,
information Is correct.I agree to comply with all city and county ordinances 359 12 004
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 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
may accrue again t said City inconsequence of the granting of this permit.
Additionally,I p(loom understands and will comply with all non-point 180 DAYS FROM LAST CALLED INSPECTION.
source regal do er the Cupertino Municipal Code,Section 9.18.
Issued by:Jasmine Archbold
Signature Date 04/06/2018 Date:04/06/2018
OWNER-BI ILDER 'CLARATION
RE-ROOFS:
I hereby affirm[rat I am exempt train the Contractor's License Law for one of the All roofs shall be inspected prior to any roofing material being iostalied.If e roof is
following two reasons; insuilled without first obtaining an nspection,I agree to remove all new materials for
r. I,as owner of the property,or my employee with wages as their sole inspection.
ompensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044,Business&Professions Cade) Sig name ofApplierm:
z 1,as owner of the property,am exclusively contracting with licensed Date:04/06/2018
contractors to construct the project(Sec.7044,Business&Professions Code).
1 hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
r. I have and will maintain a Certificate of Consent to self-insure far 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 readthe hazardous materials requirements under Chapter 6.95 of the
I 1 have and will maintain Worker's Compensation Insurance,as provided for by California Health&.Safety Code,Sections 25505,25533,and 25534.f will
Section 3700 of the Labor Code,for the performance of the work for which thism aint'ain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,Section 25532(.)should 1 store or handle hazardous
a. I certify that in the performance of the work for which this pemrit 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 ah-contaminants as defined by the Bay Area At,Quality Management District 1
Worker's Com asatum laws of California.If,after making this certificate of, wrll maiutahr compliance with the Cupertino Municipal 255 Code,Chapter 9.12 end
Pe g the Health&Safety Cade ons 25505,25533,and 25534.
exemption,I become subject to the Worker's Compensation provisions of the
Labor Code,I.,,,at forthwith comply with such provisions or this permit shall
be deemed revoked. Ownerorauthorized agent:
Date:04!06!2018
APPLICANT CERTIFJCAT[ON CONSTRUC
I certify that I have read this application and state that the above information is 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