B-2018-1174 CITY OF CUPERTINO BUILDING PERMIT
ARS AMERICAN
RESIDENTIAL
SERVICES OF
CALIFORNIA INC
MEMPHIS,IN 38120
OWNER'S NAME:Maclin George F And Norma J DATE ISSUED:07/12/2018
OWNER'S PHONE: PHONE NO:(408)283-9536
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C20•C36 Lie.#742039
Contractor R 5AMERICAN RESIDENTIAL SERVICES OF CALIFORNIA INC X BLDG—ELECT_PLUMB-
Date 1013112019 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 GAS SPLIT SYSTEM FURNACE AND A/C-LIKE FOR
LIKE SAME LOCATION
I hereby affirm under penalty of perjury one of the following two declarations:
t. 1 have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Cade,far the
/!11/performance of the work for which this permit is issued.
i have and will maintain Worker's Compensation hnsurance,as in for by
Section 3700 of the Labor Code,fm'the performance of the work for which this Sq.Ft Floor Arca: Vnmotion:$11267.00
permit is issued.
APPLICANT CERTIFICATION
1 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 362 01 016
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 er the Cupertino Municipal Code,Section 9.18.
Issued by:Jasmine Archbold
Signature �� Date 07/12/2018 Date:07/12/2018
OWNER-BUILDER DECLARATION
RE-ROOFS:
1 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.III roof is
following boo reasons: installed without Grst obtaining an inspection,I agree to remove all new materials for
r. 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(Scc,7044,Business&Professions Code) signora.ofApplicann
z I,as owner of the property,am exclusively contracting with licensed Date:07/12/2018
contractors to construct the In eject(Sce.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
t. I have and will maintain a Certificate of Consent to self-insure for Workci'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 nnaterfals requirements under Chapter 6.95 of the
2. 1 have and will maintain Waricer's Compensation Insurance,as In for by California Health&Safety Cade,Sections 25505,25533,and 25534,twill
Section 3700 of the Labor Code,for the performance of the work for which this maintain compliance with the Cupertino Municipal Cade,Chapter 9.12 and the
permit is issued. Health&Safety Code,Section 25532(x)should I store or handle hazardous
s. I certify that in the performance of the work for which this permit k issued,1 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 contamtnafin
tutorials as deed by the Bay Area Air Quality Management District 1
wlll maintain compliance with the Cupertino Municipal Cade,Chapter 9.12 and
Worker's Compensation laws of California.If,after making this certificate of the Health&S arety
Safety Code,S •tions 25505,25533,and 25534.
exemption,I become subject to the Worker's Compensation provisions of the //'� /q� —
Labor Code,I must forthwith comply with such provisions or this permit shall Owner or authorized agent: t
be deemed revoked. Data:07/12/2018
APPLICANT CERTIFICATION C.ONS'1'RUCTION 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 properly for inspection purposes. (We)agree
to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Address
judgments,casts,and expenses which may accrue against said City in
consis once 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 understand my plans shall be used as public records.
Code,Section 9.18.
Licensed