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B-2016-2699 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2699 21671 LINDY LN CUPERTINO,CA 95014-4807(356 22 017) F W H ACQUISITION CO LLC BOTHELL,WA 98011 OWNER'S NAME: KUAN DARWIN AND LILLY C TRUSTEE DATE ISSUED:09/12/2016 OWNER'S PHONE:650 417 1687 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 X PLUMB I hereby affirm.that I am licensedunder 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: I hereby affirm under penalty of perjury one of the following two declarations: REMOVE/REPLACE WATER HEATER 38 GALS 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:$0.00 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 356 22 017 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 18� 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:09/12/2016 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 s. 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. 1,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 s. 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. d 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 snaking 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 Lenders Address consequence of the granting of this permit. Additionally,the applicant understands ARCHITECT'S DECLARATION and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 1 understand my plans shall be used as public records. Licensed Signature Date Professional vrr..�■�rt�. ■ �..��■ 1'1.1{-r VIVM 11V1Y COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION 'vt e to 10300 TORRE AVENUE•CUPERTINO CA 95014-3265 1 C GUPERFNQ - (49q).777-5221O.-FAX(408)777-3333 b •I e c M71SC .. PLUMBIN17 IIANICAL ELECTRICAL MISCELLANEOU PROJHCT.ADDRESS � ( L� L1v � ` REN OWNER NANDCj Y PNO F.-MAIL STREET ADDRESS WJ I L 4\I` N YI S AT IP�1 CA 4 S C�, J FAX CONTACT NAME a_10 CL VPHONE `]-MAIL STREET ADDRESS CITY,STATE,ZIP FAX OWNER ❑ OWNDR-HU[LDER ❑ OWNERAoHN7 9&QNMCTOK ❑CONTRACTOR AGENT ❑ ARCMT[HCT ❑BNOINHHR 11 DEVELOPER TENANT CONTRACTOR NAME 11 ,� L[CHNSH NUtvIDER Q (1LICENS T FPHNS 1 Q f COtvQ�ANY NAME lww >,MA L t� 1 97TtEET ADDR99S � abo S- C. rrrr.STA ,zt ARCHITECTYENOwEER NAME! LICENSE NUMBER EUS.LIC Y COMPANY NAME e•MAiL PAX STRISIT ADDRESS - F[iONG CITY,STATE,ZIP - - . FLBUSq'LDJNG: OE sroorDUPLEX © MULT[FAMILY PROI6CTINWD.DLAND LIvEs PROMCTIN ❑YH6 ISTHBBLDpAN D XSS ❑COMWRCIAL MANINf9RFACEARRA 1111NO FLOOD ZOM NO DiCt•H.ER ROME? ❑NO CRIPT[ON OF WORK r1VA Y 9 certify to each of the following; I am the prop®ny owner or authorized agent to act on the property owner's behalf; I have read this mation 1.have provided is correct, r have read the Description of Work and verify it is accurate. (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 for inspection purposes, Signature of Applicant/Agent: Q"—^�� Date; SUPPLEMENTAL INFORMATION REQUIRED tr7 .Of M1 PNlIscA1;y�_201/aloe revised 06/21/(f