B-2019-0507 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2019-0507
11592 BRIDGE PARK CT CUPERTINO,CA 95014-5100(366 52 057) A R S AMERICAN
RESIDENTIAL
SERVICES OF
CALIFORNIA INC
965 RIDGE LADE
BLVD 201 MEMPHIS,
TN 38120
OWNER'S NAME: DATE ISSUED:03/25/2019
OWNER'S PHONE: PHONE NO:(408)283-9536
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class WARM-AIR HEATING,VENTILATING AND AIR-CONDITIONING
Lic.#742039 X BLDG —ELECT —PLUMB
Contractor R S AMERICAN RESIDENTIAL SERVICES OF CALIFORNIA INC X MECH X RESIDENTIAL_COMMERCIAL
Date 10/31/2019
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing JOB DESCRIPTION:
with Section 7000)of Division 3 of the Business&Professions Code and that my REPLACE FURNACE LIKE FOR LIKE;INSTALL(N)A/C IN
license is in full force and effect. BACKYARD
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
performance of the work for which this permit is issued.
2. I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$12622.00
Section 3700 of the Labor Code for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION APN Number: Occupancy Type:
certify that I have read this application and state that the above 366 52 057
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 PERMIT EXPIRES IF WORK IS NOT STARTED
inspection purposes. (We)agree to save indemnify and keep harmless the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
City of Cupertino against liabilities,judgments,costs,and expenses which
may accrue against said City in consequence of the granting of this permit. 180 DAYS FROM LAST CALLED INSPECTION.
Additionally,the applicant understands and will comply with all non-point
source
Date 3/25/19
RE-ROOFS:
OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of the installed without first obtaining an inspection,I agree to remove all new materials for
following two reasons: inspection.
1. 1,as owner of the property,or my employees with wages as their sole
compensation,will do the work,and the structure is not intended or offered for Signature of Applicant:
sale(Sec.7044,Business&Professions Code) Date:3/25/19
2. I,as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three declarations:
1. I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will
2. I have and will maintain Worker's Compensation Insurance,as provided for by maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Section 3700 of the Labor Code,for the performance of the work for which this 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
will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
shall not employ any person in any manner so as to become subject to the the Health&Safety Code,Sectip rs25505,25533,and 25534.
Workers Compensation laws of California. If,after making this certificate of
exemption,I become subject to the Worker's Compensation provisions of the
Owner or authorized agent:
Labor Code,I must forthwith comply with such provisions or this permit shall Date:3/25/19
be deemed revoked. O
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance
I certify that I have read this application and state that the above information is of work's for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws Lender's Name
relating to building construction,and hereby authorize representatives of this city
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 ARCHITECT'S DECLARATION
consequence of the granting of this permit. Additionally,the applicant understands I understand my plans shall be used as public records.