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B-2016-2216 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2216 10265 MENHART LN CUPERTINO,CA 95014-3629(375 15 027) A R S AMERICAN RESIDENTIAL SERVICES OF CALIFORNIA INC MEMPHIS,TN 38120 OWNER'S NAME: LAI KEN KAUNG AND LIN SHU FENG i DATE ISSUED:06/27/2016 OWNER'S PHONE:510-364-1670 PHONE NO:(901)271-9700 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class C-36,C-42,A Lie.#765155 Contractor A R S AMERICAN RESIDENTIAL SERVICES OF CALIFORNIA INC X BLDG —ELECT X PLUMB Date 07131/2018 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. SPOT REPAIR,INSTALL PRESSURE REGULATION VALVE I hereby affirm under penalty of perjury one of the following two leclarations: 1. I have and will maintain a certificate of consent to self-insur1' a 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 Insuranc ,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: Valuation:$1840.00 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 375 15 027 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 PE IT 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 LASS' /%LLED INSPECTION. source regulations per the Cupertino Municipal Code,Section 9.18. / Issued by:Alex Vallelunea Signature Date 27 2 1 Date:06/27/2016 OWNER-BUILDER DECLARATION RF ROOFS: I hereby affirm that I am exempt from the Contractor's License aw 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 i. I,as owner of the property,or my employees with wages�s their sole inspection. compensation,will do the work,and the structure is not' tended or offered for sale(Sec.7044,Business&Professions Code) a Signature of Applicant: i. I,as owner of the property,am exclusively contracting with licensed Date:6/27/2016 contractors to construct the project(Sec.7044,Business&J Professions Code). I hereby affirm under penalty of perjury one of the following thr a declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER i. 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 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. 1 will Section 3700 of the Labor Code,for the performance ofa 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 s. I certify that in the performance of the work for which thi 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,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 Labor Code,I must forthwith comply with such provisions or this permit shall Owner or authorized agent: be deemed revoked. Date:6/27/2016 APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the abo a 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 sa'd City in consequence of the granting of this permit. Additionally,the adplicant understands ARCHITECT'S DECLARATION DECLARATION and will comply with all non-point source regulations per the Cdpertino Municipal I understand my plans shall be used as public records. Code,Section 9.18. Licensed GENERAL PERM T APPLICATION MEP COMMUNITY DEVELOPME, T DEPARTMENT• BUILDING DIVISION 00 10300 TORRE AVENUE^ CPERTINO, CA 95014-3255 ' r. `?�" ... IS C (408)777-3228 FAX(408) 77-3333• building(d.)cuoertino.orq CUPERTIN0 _ []PLUMBING _ ❑MECHANICAL ❑ELECTRICAL ❑A/ISCELLANTEOUS PROJECT P.DDRESSO��S n n _ APN n C S-7 S V Z: OAVNER NAME 1 VL PHONE / J E-h/AIL STREET ADDRESS CITY, STATE,ZIP FAX CA 9S o 1 k CONTACT NAIViEPHONE E-MJiAILr -I J 15 0.(•S STREET ADDRESSTo TY,STATE,ZIP FAX �oS PGS o CA S 1 2 . ❑ WkIN'ER ❑ OWNER-BUILDER ❑ O1WNER•AGFNT ❑ C14CTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGIRTEER ❑ DEVELOPER ❑ TENANT COh'TRAC 'AME LICENSE NU]vIBER LICENSE TYPE BUS.LICA', e,r rosy S C3�eL 2- 2►5'o COMPA1vY '.A1 S QA �C�' � 4e� E-MAIL pa(S M Ol ��J•Cpwl FAX �[� STREET ADDRESS CITY,STATE,ZIP PHONE 2-'60'3pc>� b D� . Sa,�\'So AR CHITECT/ENGINEER 1\?A7 4E LICENSE NUMBER BUS.LIC COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF -I-SFD orDUPLEX ❑ MULTI-FAMILY PROJECT IN RiILDLAND ❑ YES PROJECT IN El YES IS THE BLDG AN ❑YES BLTII.DLNG: ❑COM MEPCLAL I URBAN INTERFACE AREA El NO FLOOD 201.'E ❑ NO I EICHLER HOME? ❑ NO DESCRIPTION OF WORK � � �n 1��- `�-�� V 6J VC_ I� TOTALV.ALUATIO RECEIVED B', 'f z t o :.. By my signature Row,I.certify to each of the following: I am the p opera+owner or authorized agent to act on the property owner' behal. ave read this application and the information I have provided is correct. I have real the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relat• a to building construction. thorize representatives of Cupertino to enter the above-identifi d property for inspection purposes. Signature of Applicant/Agent: Date:. � SUPPLEMENTAL INFORMATION REQUIRED h ❑;E7tPRE§S W. 4 �'rN. T7AJOIt :;:. .:-... .......-.2.5 .. ?.,� AIEPAliscrlpp_201].doe revised 06121/11