B-2018-1045 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1045
1053 COLONY HILLS LN CUPERTINO,CA 95014-5801(359 30 005) A R S AMERICAN
RESIDENTIAL
SERVICES OF
CALIFORNIA INC
MEMPHIS,TN 38120
OWNER'S NAME: DATE ISSUED:06/20/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class 0124 Lic.#742039
Contractor A R S AMERICAN RESIDENTIAL SERVICES OF CALIFORNIA INC XBLDG_ELECT_PLUMB
Date 1 013 112 0 1 9 X MECH X RESIDENTIAL_COMMERCIAL
I hereby affirm that 1 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);INSTALL(N)A/C UNIT
I hereby affirm under penalty of perjury one of the following two declarations:
r. I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided For by Section 1111,111,Labor Code,For the
performance ofte hwork for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by
` Section 3700 of the Labor Cade,for the performance of the work for which this Sq.Ft Floor Area: Valuation:$23558,00
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above APN Number: Oceaponey Type:
information is correct.I agree to comply with all city and county ordinances 359 30 005
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 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 LAST CALLED INSPECTION.
source regulations per the Cupertino
,Municipal Code,Section 9,18,
!/
Date 06-20-2018 Date:06/20/2018
OWNER-BUILDER DECLARATION RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Low for one of the All roofs shall he inspected prior to any roofing material being installed.If a roof is
fallowing two ovium so installed without first obtaining an inspection,l agree to remove all new materials for
v 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(Sce.7044,Business&Professions Code) Signature ofApplicank
z. I,as owner of the property,am exclusively contracting with licensed Date:06-20-2018
contractors to construct the project(Sec.7044,Business&Professions Cade).
I 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 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, 1 have read the hazardous materials requirements under Chapter 6.95 of the
z. I have and will maintain Worker's Compensation Insurance,as provided for by California health&Safety Cade,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
permit is issued. Health&Safety Code,Section 25532(a)should 1 store or handle hazardous
a. I certify that in the performance of the work for which this permit is issued,I material.Additionally,should I use equipment or devtces which emar
it hazdous
shall not employ any person in any manner so as to become subject to the ohcontaminants as defined by the Bay Area Alr Quality Management District 1
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,
exemption,I become subject to the Worker's Compensation provisions of the
Labor Code,1 must forthwith comply with such provisions or this permit shall Owner or authorized agent:
be deemed revoked. Date:06-20-2018
APPLICANT CERTIFICATION CONS'f1fUCT10N 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.
Cade,Section 9.18.
Licensed