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B-2016-1855 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1855 21870 EATON PL CUPERTINO,CA 95014-1180(326 19 132) F W H ACQUISITION CO LLC BOTHELL,WA 98011 OWNER'S NAME: KAN WAIFU AND JACOB PAMELA TRUSTEE DATE ISSUED:04/29/2016 OWNER'S PHONE:408 780 8068 PHONE NO:(425)636-7078 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class PLUMBING Lic.#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 50 GALLON GAS 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. 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:$1575.00 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 ordinances APN Number: Occupancy Type: and state laws relating to building construction,and hereby authorize 326 19 132 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 WORD IS NOT STARTED may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature Date Issued by:Patricia Garcia Date:04/29/2016 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. 1,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 construct 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 r. 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. 1 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. I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the 3. 1 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 04/29/2016 FRI 9: 02 FAX FaI9t water HOa.tOr Q tS(iIVV4/ VVj GENERAL PERMIT APPLICATION MEP • COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 MISC CUPERTINO (408)777-3228-FAX(408)777-3333•buildingacupertlno.org c>2C3!10-- i 55 ba LUMDING MECHANICAL ELECTRICAL MISCELLANEOUS PROJECT ADDAE9S AI'N 11 OWNL'R NAME IPTiONF1'/ D L•MAiI, 1 V� STREET ADDRESSIn CITY,STATE,ZIP �r`�j�� FAX • r , O-0 CONTACT NAME PHONE E-MAIL STRECf ADDRESS CITY,STATE, ZIP FAX ❑OWNER ❑ OwNFK-auILDER ❑ OWNER AGENT �NTRAcTOR ❑CONIRACTORAGt?NT ❑ ARcFuTecr ❑ENGINEER ❑ DI%VE(.OPBR ❑TENANT CONTRACTOR NAME I (, LICENSE N LICE N YF DUS, AC u O COMPANY NAMDvleL 'CI�^ MAIL r h r•Ax STREB'T•ADDRE I S T n r� CI ARCHITEC17ENOINEER NAM13 l! LICENSE_NUMBER ` BUS.LIC 0 COMPANY NAME EMAIL FAX STREET ADDRESS CfiY,STATE.ZIP PHONE USE OF ;WrD or DUPLE ❑ MULTI-PAWOLY PROJECT IN WILDLAND ❑ YES PROTECT IN ❑YES IS T}IE BLDG AN ❑ Yt0.9 BUILDING, ©COMMERCIAL URBAN INTBAPACB AREA ❑ NO FLOOD ZONE ❑NO 91CHLER HOMO ❑NO DESCRIPTTONOF WORK gRei-/� t^ ` : I C �4 •n IJV{s!., V (� •` !r. TOTAL VALUATION: By my signature below,l certify to cath of the following; I am the property owner or authorized agent to act on the property ownar's behalf. I have read this application and the information I have provided is correct. I have rend the Description of Work and verify It is accurate. l agree to comply with all applicable local ordinances and state laws relating to building c nstruction,nnl authorize representatives of Cupertino to enter the above-idrendflod roperty for inspection purposes. SignahaeofAppiicant/Agent: �'�sea- � Date;_ �i'�Ol�f� SUPPLEMENTAL INFORMATION REQUIRED • I''a l� ern„ ••;1'r)•„-''y � r'''?''•ti• !,%�+ •kp 8d-';��),:'�L•�:�:,•s,l.,i_'411�'^'l�i��'•��i,•1'��,•�'I 7�•� i V,lei 'Y. '•i"i t. dd/dPAdiscApp_20/I.doc revised 06/2//1/