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B-2016-2531 CITY OF CUPERTINO BUILDING PERMI BUILDING ADDRESS: CONTRACTOR: PE 011T NO:B-2016-2531 19957 BEEKMAN PL CUPERTINO,CA 95014-2452(316 30 140) F W H ACQUISITION CO LLC BOTHELL,WA 98011 OWNER'S NAME: BILLERBECK BR`IED AND KRISTIN D DATE ISSUED:08/17/2016 OWNER'S PHONE:408 334 3754 PROT iE NO (425)636-7078 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INF License Class PLUMBING Lic.#987398 Contractor F W H ACQUISITION CO LLC Date 10/31/2017 X BLDG —ELECT _PLI JMB I hereby affirm that I am licensed under the provisions of Chapter 9(commencing 1ECH X IRESIDENTIA —COMMERCIAL with Section 7000)of Division 3 of the Business&)Professions Code and that my license is in full force and effect. JOB DESCRIPTION: I hereby affirm under penalty of perjury ury one of the following two declarations: WATER HEATER 38 GALL NS 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. 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:$1554.00 APPLICANT CERTIFICATION 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: Occu aney Type: and state laws relating to building construction,and hereby authorize 31630 140 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 EXPIRE IF WORK IS NOT STARTED may accrue against said City consequence of the granting all this permit. WITHIN 180 DAY 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:08/17/2016 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS: j following two reasons: All roofs shall be inspected pric r to any roofing material being installed.If a roof is j 1. I,as owner of the property,or my employees with wages as their sole installed without first obtaining 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 COVE GS TO 11E CLASS'°A"OR BETTER 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. 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. I will permit is issued. maintain compliance with the uperdno Municipal Code,Chapter 9.12 and the s. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Secti n 25532(x)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 b 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 lode,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 CON TRL CTION LENDING AGENCY correct.t 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 ARCH] ECT'S DECLARATION and will comply with all non-point source regulations per the Cupertino Municipal Code,_Section 9.18. I understand my plans shall be used as public records. Licensed Signature Date Professional E2/003 [Lai COMMUNITY DEVELOPMENT DEPARTMENT,BUILDING DIVISION ��� r 10300 TORRE AVENUE CUPERTINO,CA 95014-3255 CUP�R�FF1Vfl (408)777-3228•FAX.(408)777-3333 I n ertlno o 4U M-1.S C I.UMBINQ QMKHANICAL ELECTRICAL PROreCTADDRESS SCELLANEOU$ l. APN N _ OWNER NAME rR PHO F_M , 33 c, �3 Q I,C STREET ADDRESS t �` h CITY,9'CA?E,Z �,� .�, C/-1- FAX CONTACT NAME 0 �pp ryl PHONE Mi STREETADDRP,SS (Jti� Ih4�i i u rJC IYIGC CITY,STATE,ZIP FAX f ©OWNER ❑OWNER-BUILDER ❑OWNERAOENT -13T CO rrrrUlCl-OR 000NTRACIORAOBNT ❑ ARCEEIIfCT BNOMeFR 11 [)EVELOPBR E3 TENANT CONTRACTOR NAME h n V LICENSE KU C Q L(CENS V EUS,WC a COM31ANY NAME MAIL FAX STREET ADD 5 L N I�.4,� p CITY, T P 11 �L V P[ONE (� y ARC[ TBCT/BNOINEBRNANtE LICENSE Nt1MEER It BUS.•LIC a COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PrrotaE USE OF SFD OrDUPLCX ❑ N(ULT!•PAMILY PRMCT(N WCLDLAND BUILDING: [ICON ERCIAL 13 YES PROTECTw ❑TES !STFtE91.00AN - 0YDS URBAN INTEP.FACE ARRA Q NO FLOOD ZONn ©:NO EICHI.BR 140m"DESCRIPTION OF WORK ❑NO TOTAL VALUATION; BY MY signature below,I certify to-each of the following: I am the property owner or authorized agent to act on the property wrler's behalf, I have=,d this application and the information I have provided is correct, i have read the Description of work and verify it is accurate. (agree t0 comply with all applicable local ordinances and state laws relating to building oonstr coon. I authorize representatives ofCupentno to enter the above-identified property for inspection purposes, Signature of Applicant(Agent; Date; SUP ENTAL INFORMATION REQUITtED Al/EP (scXPP_zOII doe re Pis ed 0612 f/1/