B-2016-1749 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1749
906 SAGE CT CUPERTINO,CA 95014-4217(359 06 013) F W H ACQUISITION
CO LLC
BOTHELL,WA 98011
OWNER'S NAME: LINDA G TRUSTEE KOHLRUST DATE ISSUED:04/13/2016
OWNER'S PHONE:408 306 8334 PHONE NO:(425)636-7078
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class PLUMBING Lie.#987398
Contractor F W H ACQUISITION CO LLC Date 10/31/2017 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 38 GALLON GAS WATER HEATER
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. 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:$1430.00
APPLICANT CERTIFICATION
I 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 35906013
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
City of Cupertino against liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN g8®DAYS ®F PERMIT ISSUANCE ®R
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cupertino Municipal Code,Section 9.18. 180]SAYS FROM LAST CALLED INSPECTION.
Signature Date Issued by:Patricia Garcia
Date:04/13/2016
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
1. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to constrict the project(Sec.7044,Business&Professions Code). Date:
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 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. HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
3. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the material. Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in Lender's Address
consequence of the granting of this permit. Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date Professional
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GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 70RRE AVENUE•CUPERTINO, CA 95014-3255 MISC
CUPERTINO (408)777-3228•FAX(408)777-3333•Jtulldlngrtino.org�,
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UMBINO MECHANICAL MELECTRICAL MISCELLANEOUS
PR0ILCTADDRESS APNM
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CONTACT NAME F,-
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17 owNER 13 OWNER-BUILDER ❑ OWNER AOSNT ?;I4ONTRACTOR ❑CONTRACTOR AGENT I, ARCIBTECT ❑ENGINEER E] DPV13LOPM ❑TBNANT
CONTRACTOR NAME .VI&PIP L&asoly I LICENSE NUMBER TENS r BUS.LIC It cA(1 LD O
COMPANY NAMPkf- �"e E-MAIL- WR' 1 �� 1
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STREET ADDRESS CITY, TATE QIP 1 ,� qo
ARCMTECT/ENOINFER NAME LICENSE NUMBER '4 �T I HUS,LIC 0 �f
COMPANY NAMB C-MAII r FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
U99 OF 13SFD6,DUPLI3X ❑ MULTI-PAMILY PROJECT IN WB.DLAND ❑ YCS PROjecilIN ❑YES IS THE BLDG AN Ll Yes
BUILDING: ❑COMMERCIAL URBAN INTERPACI!ARVA [3NO FLOOD ZONE LINO BrCULBR IKON 9 El No
DESCRIPTION OF WORE: ,
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TOTAL.VALUATION: ' ILE �1)fita'tl1f; �';1.;.,1 ;;',�",' ,1 !f l "'•° ;•r:'. ;','';
By my signature below,I certify to each of the following: I am the property owner of authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct 1 have read the Description or Work and verify it is accurate. i agree to comply with till applicable local
ordinances and state laws relating Lo building a struction. I authorize representatives of Cupertino to enter the above-ide dfied roperry(for inspection purposes.
Signature of Applicant/Agent: Date'.
SUPPLEME.NTAL INFORMATION REQUI ED
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WATER-CONSERVING PLUMBING FIXTURES..�---
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
CUT 10300 TORRE AVENUE•CUPERTINO,GA 95014-3255
INO
(40 )77 -3 28•FAX 777-3333•buildirnga�cupertino.org
(Owner ame ` Wer—mit—No
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1�] Is your real property a registered historical site?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
No Go to Question 2.
{2] Does your real property have a licensed plumber certifying that,due to the age or configuration of the property or its
plumbing,installation of water-conserving plumbing fixtures is not technically feasible?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply.
❑ The licensed plumber's certification has been provided to the Building Division.
Skip the rest of the form and:sign_bottom of form_— _
No Go to Question 3.
(3]
Is water service permanently disconnected for your building?
El Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
No Go to Question 4.
Is your real property built and available for use or occupancy on or before January 1, 1994?
❑ No My real property is built and available for use or occupancy after January 1, 1994.
Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
Yes My real property is built and available for use or occupancy on or before January 1, 1994.
Civil Code Sections 1101.1 through 1101.8apply. Check one of the three following statements and sign
bottom of form..
Please check ONE of the following:
SyMy property is a single-family residential real property. See Civil Code Section 1101.4.
-�'On and after January 1, 2014,building alterations or improvements shall require all non-compliant plumbing fixtures
to be replaced with water-conserving plumbing fixtures throughout the building.On or before January 1,2017,all non-
compliant plumbing fixtures shall be replaced with water-conserving plumbing fixtures (regardless of whether
property undergoes alterations or improvements).
0 My property is a multifamily residential real property. See Civil Code Section 1101.5.
On and after January 1,2014,specified building alterations or improvements shall require non-compliant
_..—plumbingfixtmvsrto--tye replaced-with-wwator=conserving-tl=birig fTures
On or before January 1,2019,all non-compliant plumbing fixtures shall be replaced with water-
conserving plumbing fixtures throughout the building(regardless of whether property undergoes alterations or
improvements).
❑ My property is a commercial real property. See Civil Code Section 1101.5.
On and after January 1,2014,specified building alterations or improvements shall require non-compliant
plumbing fixtures to be replaced with water-conserving plumbing fixtures.
On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water- conserving
plumbing fixtures throughout the building(regardless of whether;property undergoes alterations or improvements).
1,as the owner or owner's agent of this property,certify under penalty of perjury that non-compliant plumbing fixtures will be
replaced prior to date specified above with water-conserving plumbing fixtures in accordance with Civil Code Sections 110 1.1
through 1101.8,the current California Plumbing Code and California Green Building Standards Code,and manufacturer's
installation requirements,and that the water-conserving plumbing fixturescom ly with the requirements as indicated in t e
table on the followingpage.
(Owner orZ7wner Agen ' ig,matur JVruaa e:
Upon completing and signing this ertificate,please return A to the Building Division in order to final your bui d ng permit.
SB4072015.doe revised 08126115