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B-2017-0324r CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0324 10226 DANUBE DR CUPERTINO, CA 95014-2146 (369 49 019) F W H ACQUISITION CO LLC BOTHELL, WA 98011 OWNER'S NAME: SRINIVASAN KRISHNAN AND SUNDARARAGHAVAN LAK DATE ISSUED: 02/28/2017 OWNER'S PHONE: 408-245-5936 PHONE NO: (425) 636-7078 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class C-36 Lic. #987398 Contractor F W H ACQUISITION CO LLC Date 10/31/2017 X BLDG —ELECT X 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: (R) 40 GAL WATER HEATER - HALL CLOSET 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. 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: $1240.00 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 369 49 019 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 FROM LAST CALLED INSPECTION. Signature \! Date 2/28/2017 Issued by: Abby A eY nde OWNER -BUILDER DECLARATION Date: 02/28/2017 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 construct the project (Sec.7044, Business & Professions Code). Date: 2/28/2017 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 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 Cupertino 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, 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 Code, Chapter 9.12 and exemption, I become subject to the Worker's Compensation provisions of the MMunicipal the Health & Safety Code, Section25533, and 25534. Labor Code, I must forthwith comply with such provisions or this permit shall 25505, be deemed revoked. L Ow e„ or authorized agent: APPLICANT CERTIFICATION Date: 2/28/2017 1 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 and state laws CONSTRUCTION LENDING AGENCY 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 2/28/2017 professional OZ/15/2017 WED 7'27 FAX Falst water Heater ?D- �Ot-4 U002/007 ,vi COMMUNITY DCVELOPMENT DEPARTMENT • WILDING DIVISION 10300 TORKIRE AVENUE - OUPERTINO, CA 9501253 Ps11� i1�A�l' (408) 777-3228 . FAX (4pe) 777-334 • j�lLls�II7cJ Q(t7�GUA@rtll7o.era 16Q MISC 4R4,ISCt' AAOR898 L'Li(_�4 a q ®tq MAIL STREST ADDRESS I r� © Com. T �,e(�. 4,12-C � VVC74..7' 1, 0 � G,12 t VAX CONTACTNAM b PHONE &MAIL STR$arAA CITY. STATE, VP RAX 0 OWNER 0 0WtM?-bUILDRR [3 owNER AggDrr CbNTRACtGR NAW CObOANY NAM S REErr ADDRM I� CONTRACTOR A©gNT CI ARCMMWr ❑ aNOINaER © DEVH MR ❑ TENANt LICEMB TYPE BUS. L04 n �\ R ARC HITECTRINaINSUR NAME LtCBNSP NUMBER COMPANY NAME H -MAIL STREET ADDRESS CrrY, STATA ZIP USE OF a�DUPLa7t MULCI.PANALY PRWBC rNWa,OLAIVD D Ya9 fho= TN ©YBS BE11LDINe tOMMMMIAL EWAN INTWACA AMA ( 0 NO FLOOD ZONE CI NO (/� DZICRIPTION.OFWORK "10 � ` 661 IZ M�- . " - 170W BUS. LIC N FAX PkM 19 Ti O KDO AN 1y3 YES BICTiLBI+�*WM? ILII NO TOTAL VALUATION - By my signature below, I certify to each of the following: t am the propetty owner or authorized agent to act on the property owner's behalf. 1 have read this application and the information t have provided Is correct, 1 kava road the Degcrlption of Work and verify It Is sccurat3. I agree to comply with all applicable local ordinences and state laws muting to ballding con ation. I authorize repreaentativee of Cupertino to eater the Rb^o^�ve-identl ed exty Ear inspection purpoaee- Signature ofApplicant/Agent Date., CJI � r kiEPiWL7cApp_,2011.doc revised /1612 r111 VZ/&1JaV.L1 MUA 11744 FAX FaAt Water Heater 10002/002 t CERTIFICATE OF LIABILITY INSURANCE FQATE(MMiQDIYYYY) TYPE OP INSURANCEAm z/10/2oz7 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFEFtS NO FIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED KVRESENTATIVE DER PRODUCER, AND THE OERTIFICATE HOLDER. (- IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the polley(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s), r PRODUCER baz7, Ands—on Agsrxay,, Ino, 600 SW 39th St, Suite 240 N NE T Kathy Howland Fr, E,(425)291-5200 FAX ,{;26)891�6iG6 ADD ES9-kat�iyhgball-andiarson.com INSURERS AFFORDING COVERAGE NAIC 0 Rent©ti WA 98007 INSURERA:A=rioa.n Statee Insurance Co an 19704 INSURED F H Acquisition Co LLC, I? S Fa$t Water Hoatlir.0a INSURERS ;Liberty Mutual Fire Insurance 23025 INAUREhC:_ 11715 North Creak Parkways #C-106 INSURER D: IN�uRER E Sotriell yam, 98011 INSURER P: ItiGVIVIVIV IVVIVIPr_Ki THIS I$ TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED EY THE POLICIES DESCRIBED HEREIN 18 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAI I) CL -AIMS. LTR TYPE OP INSURANCEAm im POLICY NUMBER P L F p LIMITS A K COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR 41Ci58601661 2/17/2017 72/17/2010 RMIURRENCE 1,444,444 T 200,000 MED EXF (Any onepoison) S 10,000 r3EN'L AQ13REQATE LIMIT AFFLIE& PER: ?+ POLICY ® I& O LOO OTHER EERSONALSADV INJURY S 2,040,440 GENERAL AGGREGATE S 210001000 PRO[riJorB-OOMFlDPAGO 7i 2,000,494 Empt Fmcnoes Llai Ina S 10,000 AUTOMOBILE LIABILITY ANY AUTO ALrrosLL O�ED AUTOS HIRE? AUTOS AUTO$ NEC! I LI i E e da OODILYINJURY (Ferpemon) R ROPILY INJURY (Perecnld4nt) S PROPERTY DAMAGE do UMBRELLA LIAe EXCESS UA@ HOCCUR CLAIMS -MADE EACH OCCURRENCE AGGREGATE $ WORKERS COMPENGATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVEOFFICERIMEMSER YIN EXCLUDED? (mandatory In NH) IpTOrILs under 0 . EnATION$ know NIA 7rC26924@S66SC25 12/7./2016 12/1/2a%7 E.L.EAOHACCIQENT S 11000,000 E,L 01$EA$E- EA EMPLOYEE 1 000,000 R.I., 41SEAS11 • POLICY LIMIT $ 1 404 044 096GRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Sohedule, maybe attached if mare apaee is required) Re: Evidence at insurance at ii%rr=@fa&twaterheatlar. e contractors State Licenses Board PO Sox 26000 Sacramento, CA 95828 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 96 CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL 8C DELIVERED IN ACCORDANCE WITH THE POLICY FIROV13IONS. AUTHORIZED REPRE&ENTATiYE Hun t /CftNE (D 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26 (2014!01) The ACORD name and logo are registered marks of ACORD INS025 (9014017