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B-2016-1498 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1498 21043 CHRISTENSEN DR CUPERTINO,CA 95014-1652(326 54 003) (F W H ACQUISITION CO LLC) BOTHELL,WA 98011 OWNER'S NAME: DAVID BAD DATE ISSUED:03/11/2016 OWNER'S PHONE:408-725-8135 PHONE NO:425-636-7054 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class Lie.#987398 Contractor(F W H ACQUISITION CO LLC)Date X BLDG —ELECT _PLUMB T I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH X RESIDENIAL—COMMERCIAL with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. JOB DESCRIPTION: REPLACE 50 GALLON WATER HEATER I hereby affirm under penalty of perjury one of the following two declarations: 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 which this permit is issued. z. 1 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:$1737.00 APPLICANT CERTIFICATION certify that 1 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 326 54 003 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(Sec.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 2. I have and will maintain Worker's Compensation Insurance,as provided for California Health&Safety Code,Sections 25505,25533,and 25534. I will 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(x)should I store or handle hazardous a. 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 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 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 1 understand my plans shall be used as public records. Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date V7/ v-!4Vto. r-ni l: .1V rrA rCIL 7 L. rra LCL nCCIL\:.WL U Q.VVL!VVL E-SCA t CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPtRTINO,CA 95014-3255 CUPERTINO (408)777-3228• FAX(406)717-3333•:building(a cuoertino.org 1-1>v^16 a. B— NEW CONSTRUCTION ADDITION RALTERATJONITI F1 REVISION/DEFpRRED ORIGINAL PERMrf# PROIEC'fDRESS 1 ^ APN It /� w �f 0 5 OWNCR NAME y'� PHONE 1�1 e-Marl. STREET ADDRESS^ gOf( r Q CITY,,Qj jV � 1 FAX CONTACT NAMErI � , ` PHONP, E-MAILf v �N �^��3 STREETADDRESS CITY, TP. IF 4 ❑OWNER 13 OWNSn-ouiLimp 17 OWNERAGBNT ONTRACTOR ❑CONTRACTOR nGPNT ❑ ARCIATFCT Ci EN01NEaR ❑ DEVELOPER D TENANT CONTRACTORNAMEsw Nl B' LICEN,T e Bus.LIC e �j 7 COMPANY NAMG U\_ E-MAIL FAX �.•` STREE r ADDRESS CITY,STATE,ZIP C V� PI)DHE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS,LIC 11 COMPANY NAME EMAIL FAX STREET ADDRESS CITY,STATS,zn, PHONE DESCRIPTION OF WORK P.XI$TINGUS16 PROPOSEDUS13 CONSTR,TYPE ASTORIES USE TYPE OCC. SQ.FT. VALUATION(S) EXISTO NEW PIOOR DEMU TOTAL AREA AREA AREA NET ARBA BATHROOM -..KITCHEN - OTI•IL3R - - Y •.`'..... RRMURHLAREA RBMODELAREA RBMODFLAREA PORCH AREA ORCK AREA TOTAL DDCK/PORCII AREA OARAGR ARP,A: DETACH nTTACtt #—DwPLLING UNITS. 19 ASI:CUND UNIT ❑YES 4RCOND'STUIIY YFS BR1NC ADDxr)? ❑NO ADDITION? []NO PRE-APPLICAT(ON []YES IPYP.S,PROVIDECOPYor IS THE BLDG AN YES I (� , pt ,y sr � TQTALVALUATION; PL,INNINGnPPLB E]No 1'LANNINOAPPROVAL Lr,TTlIR RICHLRRHOMRT No 4' d i 1 ', i i' ' ' h t.. By my signature below,I ecru fy to each of the following: I am the propotty 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 properly for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED '' ��' y�"(fir}� ' ` ;7Jo"y',; iaa <<cJ f' "�'` � <� 1 1,;�,•/"' ��SI. � �Al\'� � .�'.f.�(. �1 }�' '`� � t ��P{;IVI:'r�n l''✓,.L�� ® 111 Now SFD or Multifamily dwellings: Apply for demolition Permit for V!'"Y p fib?,�y, , r t E„ d r y t tr a {r"z ��R�n�,`�',U�a•;�°I? Qrg�T. .,1 Wo" J. for new building, building(s)- Demolition permit is required prior to issuance of building ) „ _Commercial Aid s: Provide a completed Hazardous Materials Disclosure form if an Hazardous :�,r p 1 ;',7" 'i'Ir 1^ ,i• �� 1p S1 {q�;r !.:V;C', °`, ti,N, k-:t Y.••'�' C.�1 y rdous Materittl0 aro being used as part of this project. 'M used _ Copy of Planning APProval Letter or Meeting with Manning prior to 004v,. �i 5r submittal of BuildingPermit application. ::i•it.i: '• � .!,} �!'�„'i.l>`'c.1�i' ul J$NSIItOO1�IvI�1!I:t`�fi1JAL�l`�ta.'!y't:„eY' B(dgApp_2011.doc revised 06/21111