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B-2017-0224 I ill CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: 1 PERMIT NO:B-2017-0224 7570 NORMANDY WAY CUPERTINO,CA 95014-5223(366 17 063) A R S AMERICAN 1, I RESIDENTIAL 11 SERVICES OF l CALIFORNIA INC { MEMPHIS,TN 381201 OWNER'S NAME: WONG EUGENE JIN TRUSTEE DATE ISSUED:02/07/2017 1 OWNER'S PHONE:408-889-33624 PHONE NO:(408)286-8931 1li LICENSED CONTRACTOR'S DECLARATION • BUILDING PERMIT INFO: License Class C-20 Lic.#74203911 Contractor A R S AMERICAN RESIDENTIAL SERVICES OF CALIFORNIA INC X BLDG _ELECT _PLUMB Date 10/31/2017 X MECH X RESIDENTIAL_COMMERCIAL I hereby affirm that I am licensed under the provisions of Chapter 9(commencing j 1 with Section 7000)of Division 3 of the Business&Professions Code and that my JOB DESCRIPTION: license is in full force and effect. REPLACE FURNACE AND AC(SAME LOCATION) 11 I hereby affirm under penalty of perjury one of the following two declarations: 11 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 ch this t is ssued. 0 ✓I have and will maintain Worker'sCompensation 1 Insurance,as provided for by IIII Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: 1 II Valuation:$15940.00 permit is issued. Ili APPLICANT CERTIFICATION I certify that I have read this application and state that the above APN Number: !I Occupancy Type: information is correct.I agree to comply with all city and county ordinances 36617 063 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 18If pp DAYS OF PERMIT ISSUANCE OR may accrue against said City in consequence of the granting of this permit. Y Additionally,the applicant understands and will comply with all non-point 180 DAYS FROM LAST CALLED INSPECTION. source regulations per the Cupertin Municipal Code,Section 9.18. 1 'l 11 �� Issued by:Abby A'. ende Signature Date 2/7/2017 Date:02/07/2017 1'11 IIIf ,I OWNER-BUILDER DECLARATION I 1 RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of the All roofs shall be inl.ected 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 ofApplica 2. I,as owner of the property,am exclusively contracting with licensed Date:2/7/2017 contractors to construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: ALL ROO' 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 H• ARDOUS MATERIALS DISCLOSURE performance of the work for which this permit is issued. I have read the ha ardous materials requirements under Chapter 6.95 of the 2. I have and will maintain Worker's Compensation Insurance,as provided for by California Healt &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 complianc•with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Health&Safety i mode,Section 25532(a)should I store or handle hazardous a. I certify that in the performance of the work for which this permit is issued,I material. Additions y,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 Man gement District I will maintain comp ince with the Cupertino Municipal Code, hapter 9.12 and Worker's Compensation laws of California. If,after making this certificate of the Healt, &Safety Code,S•_tions 25505,25533,and'5534. exemption,I become subject to the Worker's Compensation provisions of the I 11 Labor Code,I must forthwith comply with such provisions or this permit shall ,,06v or authorize Ild agent: be deemed revoked. Date:2/7/2017 1 + APPLICANT CERTIFICATION 1,1 ONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I hereby affirm that;Mere 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 his permit is issued(Sec.3097,Civ C.) relating to building construction,and hereby authorize representatives of this city Lender's Name 1 to enter upon the above mentioned property for inspection purposes. (We)agree 1 to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Address judgments,costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands 1, , ARCHITECT'S DECLARATION and will comply with all non-point source regulations per the Cupertino Municipal I understand my plans shall be used as public records. Code,Section 9.18. Licensed I 'Ih 1 II 1) TLC" GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION �� . 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 I (408)777-3228• FAX(408)777-3333• buildina(a cupertino.orqMISC CUPERTINO i . ❑PLUMBING ❑MECHANICAL ❑ELECTRICAL 1 ❑MISCELLANEOUS PROJECT ADDRESS / APN# L Q p 1 0(03 OWNER NAME .W� (.J A.A..Qi- `iv - ( H C ,7� ✓c ! I E-RAIL STREETADDRES7 fr� / `f/ r Y, STATE,Z P �{ I f �� FAX CONTACT NAME atrc„'5 CI (J) E-MAIL STREET ADDRESS go 5k2.4..",44 t STATE,z A f 11 4 .5412,5-,- FAX 01A Y❑ OWNER 0 OWNER-BUB-DER 0 OWNER AGENT 0 CONTRACTOR eCONTRACTORAGENT ❑ ARCHITECT 0 ENGINEER 0 DEVELOPER 0 TENANT Iq ` CONTRACTOR NAME iZid LCE i,, ENS YE BUS.LIC# ��� COMPANY NAME /3___ r E-MAILir 11 FAX STREETADDRESS d TATE,_ /-,r.� 9S �j,^ K/ / 1 ' `/, i . ,L��a Ail 'li 5.-/z„,- 5--- 1 OZ©(? � ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC COMPANY NAME E-MAIL III FAX STREET ADDRESS CITY,STATE,ZIPI PHONE 11 USE OF ❑SFD or DUPLEX 0 MULTI-FAMILY I PROJECT IN WEDLAND 0 YES PROJEC l LN 0 YES IS THE BLDG AN 0 YES D BUI ING: ❑COMMERCIAL I URBAN INTERFACE ARFA ❑ NO FLOOD 1 ONE . 0 NO . EICHLER HOME? 0 NO DESCRIPTION OF WORK i; IL ��, 6.4,4e,..-- 4.4 d 1f c%—44_ / - jL r r f • • .../ " AL - ' A . TOTAL VALUATION: / 5 `moi RECEI n Bl By my signature below,I certify to each of tte follow Gina: I am the property owner or authorized agent to aot on the property oa5ner's be al£ I have read this application and the information I have prove.-d is correct. I have r-4 the Description of Work and verify itli its accurate. I agree to comply with all applicable local ordinances and state laws relating to bui.Ing cl.ns' ction. I-.norize representatives of Cupertino to enter .e ab -identif propertyfs> Ispection purposes. Signature of Applicant/Agent: Date SUPPLEMENTAL INFORMATION REQUIRED I 'OFFIC.E USE o.ia - ,- �fl,-.O\ER-TBE C _... ... OUNTER_:':,'-::;,::i...._.. Ir El EATRESS U ❑;STANDARD•- LARGfi F3 TLAJOR MEPMiscApp_2011.doc revised 06/21/11 • !I