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B-2017-0087CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: CONTRACTOR: PERMIT NO: B-2017-0087 18620 RUNO Cr CUPERTINO, CA 95014-3865 (375 25 033) A R S AMERICAN RESIDENTIAL SERVICES OF CALIFORNIA INC MEMPHIS, IN 38120 OWNER'S NAME: SBEN KANO-PING AND CHENG CHIA-YUAN TRUSTEE DATE ISSUED: 01/17/2017 OWNER'S PHONE: 408-313-2769 PHONE NO. (901) 271-9700 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class C36 Lic. 4765_1J55 Contractor A R S AMERICAN RESIDENTIAL SERVICES 0 X BLDG _ELECT XPLUMB — 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. CLEAN-OUT AT FOUNDATION I hereby affirm under penalty of perjury one of the following two declarations: 1. 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 Code, for the performance of the work for which this permit is issued. 2, 1 have and will maintain Worker's Compensation Insurance, as provided for by Sq. Ft Floor Area: Valuation: $1800.00 Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATIONAPN I certify that I have read this application and state that the above Number: Occupancy Type: information is correct. I agree to comply with all city and county ordinances 37525033 — 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. Issued by: Kim Dunbar SignatueXDate 1/17/2017 Date: 0IL17/20-17 OWNER-RUILDER. DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is 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 sale (Sec.7044, Business & Professions Code) Signature ofApplicant: 2. 1, as owner of the property, am exclusively contracting with licensed Date: 1/17/2017 contractors to construct the project (Sec.7044, Business & Professions Code). ALL ROOF COVERINGS To BE CLASS "All OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: 1. 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 Code, for the HAZARDOUS MATERIALS-DISCLOSIRS performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the 2. 1 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 of the work for which this maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the 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 31 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 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 Labor Code, I must forthwith comply with such provisions or this permit shall owner or authorized agdnrt. be deemed revoked. Date: 1/17/2017 I ENDING AGENCY APPLICANT CERTIFICATION I certify that I 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 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 Lander'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 inT'S DELT. RATION consequence of the granting of this permit, Additionally, the applicant understands I understand my plans shall used as public records. and will comply with all non-point source regulations per the Cupertino Municipal Code, Section 9.18. Licensed GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CuPeRTMO (408) 777-3228 • FAX (408) 777-3333 • building(d)cupertino.org MISC 0--2o i�� "ING El MECHANICAL ❑ -PT ECTRTr, AL PROJECT ADDRESS r� M� 4 Le MISCELLANEOUS APN # ✓ti OWNER NAME c �. PHONE Lf M- 72, 1 -2 -1 : 97 E-MAIL STREET ADDRESS CITY, STATE, ZIP FA7{ CONTACT NAM V�An 96 L PHOS STREET ADD SSCITY, STATE, 'ZIP CA 120 FAX ❑ OWNER ❑ OWNER-BUIIAEP ❑ OWNERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CO TRACTORNAME LICE SE NUMBER _ LICENSE TYPE BUS. L CO ANY NAME R 6 e4��c� E-MAIL, \ \� PIr' FAX STREET ADDRESS i-� roc Y, STATE, ZIP n ) 37 PHONE L 61 -q &2 -0(-4 0 ARCHITECT/ENGINEER NAM LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS 1 1,19 CITY, STATE, ZIP PHONE USE OF sFD -DUPLEX ❑ MULTI -FAMILY BUILDING: ❑ CONIMERCIAL - PROJECT IN WHALAND ❑ YES URBAN INTERFACE AREA ❑ NO PROJECT IN ❑ YES FLOOD ZONE ❑ NO IS THE BLDG AN ❑ YES EICHLER HOME? ❑ NO DESCRIPTION OF WORK TOTAL VALUATION:c) t 4,D By my signature below, I certify to each of the following: I am the property owner or authorized agent to 6ct on the property owner's behalf. I have read this application and the information I 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 relaf'g to bulldin 6 art sli�ib ion. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: —" Date: SUPPLEMENTAL INFORMATION REQUIRED oFFcE USE ONLY w. ❑ OVER -THF. -COUNTER N EXPRESS v 9- © STANDARD LS El LARGE © MAJOR MEPMiscApp 2011.doc revised 06121111