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B-2016-1435 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1435 21134 LAURETTA DR CUPERTINO,CA 95014-1657(326 54 024) (F W H ACQUISITION CO LLC) BOTHELL,WA 98011 OWNER'S NAME: CHEN SUNG-MING AND CHIA-JUNG LI DATE ISSUED:02/25/2016 OWNER'S PHONE:408-677-6618 PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class Lic.#987398 Contractor(F W H ACQUISITION CO LLC)Date X BLDG —ELECT —PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH X RESIDENTIAL_COMMERCIAL with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. JOB DESCRIPTION: REMOVE&REPLACE 50 GALLON WATER HEATER IN THE SAME I hereby affirm under penalty of perjury one of the following two declarations: LOCATION 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. z. 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 permit is issued. Sq.Ft Floor Area: Valuation:$1352,00 APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct.I agree to comply with all city and county APN Number: Occupancy Type: ordinances and state laws relating to building construction,and hereby .326540242 authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments,costs,and PERMIT EXPIRES IF WORK IS NOT STARTED expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal 180 DAYS FROM LAST CALLED INSPECTION. Code,Section 9.18. Issued by:Susan Winslow Signature Date Date: / 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(See.7044,Business&Professions Code) Signature of Applicant: z. I,as owner of the property,am exclusively contracting with licensed Date: 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 California Health&Safe Code,Sections 25505,25533,and 25534. I will z I have and will maintain Worker's Compensation Insurance,as provided for t3' by Section 3700 of the Labor Code,for the performance of the work for which maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the this 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 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: APPLICANT CERTIFICATION CONSTRUCTION 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 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 ARCHITECT'S DECLARATION consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the I understand my plans shall be used as public records. Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date VZ./a7/GV10 Lrlw 0: 74A rrsA raDL nax;Vr nual;VL Ifiwvv�f vv� u S CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228-FAX(408)777-3333•huilding0cupert(no,org c �( NEW CONSTRUCTION ❑ ADDITION ALTERATION t TI ❑ REVISION I DEFERRED ORIGINAL PERMIT# PROJECT ADDRE% ii APN M 13 t4 \ OWNER NAME `S ; P ONE +� " E-MAIL STREET ADDRESS ,,1 ,'� Y 6I ,�1'^ Ly �S`v� CITY, STATE,ZIP Q Q VT'4 , FAX CONTACT NAME �A ❑OWNFR ❑ OWNER-BUILDER ❑ OWNERAGP.NT (CONTRACTOR . ❑CONTRAC.TORAGP.NT ❑ ARCHITECT ❑ENGINEER 11 DEVBLOPHR [3 TENANT CONTRACTOR NAME LICENSE NUMDE LICE B PB uus.LIC n t1C1 1 (�O COMPANY NAME ` I^ E-MAIL. 'S� FAX STREET ADDRESS .0 CITY,STATP.,TIP ptiONP, ARCHITECTip.NGINEPR NAME LICENSE 14UMBELK BUS,LIC 1/ COMPANY NAMP, E-MAIL FAX STREET AnDRI?,SS CITY,STATE,ZIP PHONE DESCRIPTION OxWORK —C) U e (V t� V EXISTING USE PROPOSED USE CONSTR,TYPP. #S'T'ORIES USE TYPE OCC. SQ.1-71 VALUATION(S) EX1STcr NEW FLUOR DEMO TOTAL AREA ARPA AREA NETAREA BATHROOM KITCHeN OTIIBR RRMODPLARPA RBMODBLARPA RRM(1OKAREA FORCPI AREA DOCK ARF..A '1'011'AL DECIUrORCr1 AREA OARAGe ARPA; DB'rACM ATTACH ff DWRLLING UNITS: IBA SFCOND UNIT YES SRCUNn STORY YIiS BEING ADDED? ❑NO ADDITION? NO M, W, PRE-API'LICA•rION ❑YES Ip YES,PROVIDFCOPY OF IS THE BLDG AN YES JJ TOTAI V LLIQ.T PLANNINOAPPLN []NO PLANNING APPROVAL LETTER RICHIARROMRI NU' By my signature below.I ccttity 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 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 relating to building construction. I authorize representatives Of Cupertino to enter the above-identified property ffoCor inspection purposes. Signature of Applicant/Agent; Date: ��J SUPPLEMENTAL INFORMATION REQUIRED rrl)f;��rcrrte ��,� •; Now SFD or Multifamily dwellings: Apply for demolition permit for �r�' d=f '- •I t << *` t ttl. ��,b`.�1"�(err l r' existing building(:). Demolition permit is required prior to issuance of building i ? Y permit for new building- (,� �� s•yl�k�l�s�rt;(l I'In' ,r{rbbql' )�' �}fvfn,y.Commercial Bldgs: Provide a completed Hazardous Materials Disclosurz 41 fo—rm �%�L;{{�Ci!ryI•,ltl�ter,u,):�'a1':��'rr C'�1r 5j 2�r�„Y��' if an Hazardous Materials arc bcitib.u. sed as art of this project. 15�;�'A ��.r`(,�,� J���:_„ i,:�R•`�i���.yl�i+t r�a ri•����Att`'rl`�;�brti't y, r���C� f i,��,f 'fl 1, Copy of Planning Approval Letter or Meeting with planning prior to Pti1. hk� �1-w r�"�i; y t' �ir'hre, lti�o�;1� i©rt,, Il�1f4t'E� Et�b1S'Pli�O'ld.u''• Y'� submittal of Building['cnnit application. 'n� cif �.•v�,4�a� „v''.Y;;Y,'�.Yr`(Z'dtY>lt i'r,�[� j 0•ivl �'tu Er�'f[lci;:,TCn�e,P.', 81dgA1jp_201 Ldoc revised 06/21/11