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B-2016-3186 CITY OF CUPERTINO BUILDING PERMIT - BUILDING ADDRESS: CONTRACTOR: 1 PERMIT NO:B-2016-3186 1111 DERBYSHIRE DR CUPERTINO,CA 95014-5004(362 20 026) F W H ACQUISITION ' CO LLC 1 BOTHELL,WA 98011 OWNER'S NAME: VENKATARAMAN SHANKAR AND RAJAGOPALAN SUDHA { DATE ISSUED:11/30/2016 I OWNER'S PHONE:408-888-6918 1 PHONE NO:(425)636-7078 • LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: ` 1 License Class C36 Lic.#987398 Contractor F W H ACQUISITION CO LLC Date 10/31/2017 X BLDG __ELECT X PLUMB MECH X RESIDENTIALCOMMERCIAL I hereby affirm that I am licensed under the provisions of Chapter 9(commencing — _ with Section 7000)of Division 3 of the Business&Professions Code and that my 1 license is in full force and effect. JOB DESCRIPTION: REPLACE 40 GAL WATER HEATER(GARAGE) 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. 7'd 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:$1580.00 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 362 20 026 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 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 F •-k' _ 1 INSPECTION. Signature V VY11 Date 11/30/2016Issued by:MEL ,:n_+ .o ( ' Date: 11/30/2016 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 I inspection. sale(Sec.7044,Business&Professions Code) 1 2. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant: I contractors to construct the project(Sec.7044,Business&Professions Code). Date:11/30/2016 1 . a 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 i 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 rvith 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. t Owner or authorizedl agent, '`V APPLICANT CERTIFICATION Date:11/30/2016 `'` Icertify 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 c - 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. I understand my plans shall be used as public records. a Signature_ Date 11/30/2016 Licensed Professional 11/ZZ/Z016 TUE 9143 FAX Fast Water Heater 1004/013 '2_1i...0001.-7. \r•, ; uacICrula- ecKEWH I ArrLIc,:A 11V111 : lin1 COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION ti r ! c+,\;; 10300 TORRE AVENUE•CUPEI TING,CA 50'14-3266 C-U•Peit-T--N O- . (400 777-3228.•EA)c.ope)777-3333• !d n e I Mil S C ,r:PLUM13INt3 MECHANICAL BLECTIZ)CA r�t�l / U C L Nt15CBLLANE0U8 PROJECT ADDRESS 1 I PLANER NAMEPH4 U 1 'k Al r ~ •e� `1 `,O a i LOQ / (}f STREET AbDkt35$ ,�(�� p n J 1 k i,I 0 w i 1 {1,...e e, / CITY.9'�4T 2%/ .�, 6' /. i.` UI FAX V-1 frta CONTACT NAME PHONE - STREET ADDRESS I CITY,STATE,Zip PAX 0 OWNER 13 OWNHRBUILDER 0 OWNER AOSNT coNlttACTOR ❑CONtRACroo/wpm © ARCHITECT D ENGINEER 0 DEVELOP1R 0 TENANT CONTRACTOR NAMEU ee st,0 LICENSE NUMBER C3Q3�b !, .. COMPANY NAMEfits \,..„3 (l` L E-MA.. (• + — STREET ADDRESS 4,4„ t CTTY :TATE,ZIp (\,i() `� '^43(z) / 1)( _...., � if (. J ` ,� r(Jj4 • �" ,i() t PH.....".✓�ID" 'l J1 41 ARCHITECT/ENGINEER NAME BUS,LIC @ COMPANY NAME E-MAL PAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF .,SEO CrDUPL51t 0 MULTI-FAMILY PROJECT iN WQ.DLANO 0 Yea PROJECT IN ❑YES IS THE BLDG AN Cl YES 1 ` BUILDINQ:. • ONm>riRCIAL URBAN TNtERFAca AREA [) NO FLOOD ZONE 13 NO EICHLBDHONE? ❑NO i DESCRIPTION OF WORK J +� I./A./..),Q, L/ ,/ ,a # . m f / .4A/ 0 A., { , Jf ' '19 v S —.ver/ TOTALVALVATION; W« ;4e111 , iE � fYO � F ,.1 trfl Y ;a ; ,�.-' j �Rltei/ , tr } i) W ,,� t�. By my signature below,I certify to each of the following; I am the property 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 co struction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes, Signature of Applicant/Agent: (- --'----- Date;'; '-.., L— ,,r SUPPLEMENTAL INFORMATION REQUMED f1 I -It,••• :•i i. ,,,',, ,; ' I T. J 11.J'irM7yi!1-I.,'1;.. ''''1.r i Z��V,i;7i i;Ac `i?. { 11MEPMIsciipp_201/,doc revised 06/21/II