B-2017-0558CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-0558
10893 LEAVESLEY PL CUPERTINO, CA 95014 (356 15 026)
A R S AMERICAN
RESIDENTIAL
SERVICES OF
CALIFORNIA INC
MEMPHIS, TN 38120
OWNER'S NAME:. BARKER CHARLES B 3 AND SUSAN M TRUSTEE
DATE ISSUED: 04/10/2017
OWNER'S PHONE: 408-252-3493
PHONE NO: (901) 271-9700
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class C-36: C-42: A Lic. #765155
Contractor R S AMERICAN RESIDENTIAL SERVICES OF CALIFORNIA INC
X BLDG —ELECT X PLUMB
MECH X RESIDENTIAL _ COMMERCIAL
Date 07/31/2018
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.
INSTALL (N) TANKLESS WATER HEATER - GARAGE
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.
% I 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: $10948.00
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
35615 026
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.
sour regul ions per the Cupertino Code, Section 9.18.
Issued by: Abby Ayende
Signature Date 4/10/2017
Date 04/10/2017
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
1. 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: 4/10/2017
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
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 25505, 25533, and 25534.
exemption, I become subject to the Worker's Compensation provisions of the
t
Labor Code, I must forthwith comply with such provisions or this permit shall
9i;w :r or authorized agent: O
be deemed revoked. <-Date•
4/10/2017
LENDING AGENCY
APPLICANT CERTIFICATION
certify that 1 have read this application and state that the above information is
CONSTRUCTION
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
DECLARATION
consequence of the granting of this permit. Additionally, the applicant understands
ARCHITECT'S
I understand my plans shall be used as public records.
and will comply with all non -point source regulations per the Cupertino Municipal
Code, Section 9.18.
Licensed
&20 n— 05 8
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION MEP
10300 TORRE.AVENUE • CUPERTINO, CA 95014-3255
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(408) 777-3228 •FAX (408) 777-3333 • buildino(a�cupertino.ar
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❑ OwNER ❑ OWNER -BUILDER ❑ OWNER AGENT COArTRACTOR ❑ CONTRACTOR AGENT ❑. ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TEN -,,NT
CONTRACTOR NAME44
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USE OF . ' . ❑ SFD oT DUPLEX
BUILDING: ❑ COMMERCIAL
❑ MULTI -FAMILY
' PROJECT IN 7tAND ❑ YES
URBAN INTERFACE AREA ❑ NO
PROJECT IN ❑ YES
FLOOD ZONE ❑ NO
15 THE BLllG AN ❑ 17BS
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
TOTAL VALUATION:
hi
RECEIVED BY x
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By my signature below, I certify to each of the following: 1 am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the infolmanon 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 relat to building coon. i authorize representatives of Cupertino to enter the above -identified property for inspection proposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED
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MEPA1iscApp 2011.doc revised 06121111
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