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B-2017-0421CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: : B-2017-0421 7933 OCTOBER WAY CUPERTINO, CA 95014-4124 (362 12 027) F W H ACQUISITION CO LLC BOTHELL, WA 98011 OWNER'S NAME: LIOU JIUNN-YAU TRUSTEE DATE ISS D: 03/14/2017 OWNER'S PHONE: 408-257-8693 PHONE NO: 425) 636-7078 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class L3L Lic. #987398 Contractor F W H ACQUISITION CO LLC C 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: REPLACE 50 GAL WATER HEAT R (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. z. 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: $ 252.00 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 pe: and state laws relating to building construction, and hereby authorize 362 12 027 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 ORK IS NOT STARTED may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS O 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 LAS C INSPECTION. \J Vz-Signature. �A Date 03/14/2017 Issued by: MELI A OWNER-BUIE DER DECLARATION Date: 03/14/2017 I hereby affirm that I am exempt from the Contractor's License Law for one of the RFc All roofs shall be inspected prior to an3 ROOFS: roofing material being installed. If a roof is following two reasons: 1. 1, as owner of the property, or my employees with wages as their sole installed without first obtaining an inspe ction, I agree to remove all new materials for compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) z. 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: 03/14/2017 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS I O 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 AlERIALS DISCLOSURE z. I have and will maintain Worker's Compensation Insurance, as provided for by I have read the hazardous materlah 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. 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 material. Additionally, should I use a uipment or devices which emit hazardous shall not employ any person in any manner so as to become subject to the air contaminants as defined by the Bi y 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, ections 25505, 25533, and 25534. Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agent: i APPLICANT CERTIFICATION Date: 03/14/2017 I certify that I have read this application and state that the above information is CONSTR TI I hereby affirm that there is a constrL LENDING AGENCY ction lending agency for the performance correct. 1 agree to comply with all city and county ordinances and state laws of work's for which this permit is issu A (Sec. 3097, Civ C.) relating to building construction, and hereby authorize representatives of this city 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 understand's DECLARATION and will comply with all non -point source regulations per the Cupertino Municipal I understand my plans shall be used as public records. Code, Section 9.18. Licensed Signature Date 03/14/2017 Professional 03/06/2017 MON 12:09 FAX Fast water Heater c f�j0571093 t9l_svr_iKJ%kL t"r-KIVII I A eV1-* ;A I TUN (% '� GOMNiUNiTY DI:VEGOpMENT DEPAIRTMENT A 13VIL.DING DIVISIrON ' 10300 TORRE,0.VENl1E • CUPERTINO, GA 95014-3265 MISC (aQ6) 777-3228,• FAX.(t0q) 7773333 f7,U/-®c,E2/ PL MBING MECHANICAL BL13CTRICAL. _ _ _ Elea ELLANEOUS PROMCT ADDRESS ,�� A$NO OWNER NAME I i irakinm ALA... PFf D fy E MAI STREBT ADDRESS-7q,CPCY, STATE, ZiF FAX CONTACT NAME t RFt _ STA.BST ADMSS 1CM)A4�' CITY, STATS, Zt o FAX DW W p OWNS&BUILDER OWNBIR AaBNT ❑ CONTRACTOR d CONTRACTOR AOBNT ❑ ARCMTBCT I IN©PM13K ❑ DBVBLOPER ❑ UNANT CONTRACTOR NA!r2,,. LC, ii T LICBN38 NUMBER �rQ yQ Q r J LICgtJ58 TYi+B lr (� 6U5, LIC I! pC COMPANY NAME. B -MAA / {� 4, A -Z, f, r. PAX 07 STRUT ADDIUM CYtY, STATE, ZIP PiXbNE �- �A�D ARCWTECTIENOINBBR NAME LICENSE NUMB= BUS. LIC k COMPANY N"M i;MAIL VAX STRBifi ADDRESS CITY, STATTi, Mp PHONE USE 01' p sFD arDUFGB% ❑ MUT.TI-PAM LVFROJ$CT IN WR DLAND ❑ YI13 PlLQ18Ci IN tl YS$ IS THE BMG AN �i Y88 6U1Lp1NOt �COMNIBItCfAI UIWANtMRFACBAIWA ©PID @LOODiONe EJ No EICHLERHME? [� No DEBCRrB TON OF WORK � 4- i � .� r i TOTAL VALUATION: By my signature below, l certify to application and the Information I hi Ordinances and state laws relating Signature of Applicanr/Agent: —I of tho following: I am the property owner or atithorized agent toad on the property ovided is correct I read the Description of%rk and verify It b accurate. lag, ding � orisfryc400 a rize representatives of Cupertino to enter the above-identif Date:--.—'�- -� ner's b®half. I have read this to comply with ell appilcable local propevy for inBpection purposes, .1_7 2011.dac revfssed 06121/11 ver ori Zvi r L%Vir ti: 4k% Z' A razz Water Heater 0002/002 ACROF CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDDIYYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON rHE CERTIFICATE HOLDER. THIS CERTIFICATE DUES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAC E AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISI UING INSURER(S), AUTHORIZED REPRESENTATIVE; OR PRODUCER. AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the P011cy(3e8) must be endorsed, If SUB ZOGATION IS WAIVED, sutr)ect to the terms and pond itlone of the policy, certain Poticlee may require an endorsement. A statement on this cart ficate does not confer rights to the certificate holder in Ileu of such endorsements . PRo4uceRNCON � Kathy jjoW ,and 8el1 Anderson A Tr Yr Ina, WILL . (425) 291-•5200 1 FAx t$26)P41�6140 Satz SW 39th at, Suite 200 M IL AGG EBS k&t}Yy116Y76LZ-3h$9Z84ri.com INSURERS AFFORDING CO, AGE NAIC0 INWA 998057INSURERAA891atriCaRn Statea Ina uranco Company 19704 INSURED uRED INSURV s ,Libett Mutual Fir•13Insurance 22p25 F'PM Acqui,gition Cc LLC, DS&I Fast water Keat 4r GQ INbuREd4: 11715 North Craiak Parkway a #G-106 EmrA Ara' sea LIab Ins $ 10,000 INSURER D: INaURSR E Bothell WA 98011 r_r%1100Ar*ng INSURER P 1SCV10 IV MVIVIOCIV. THIS IS TO CERTIFY THAT THE POLEV V INSURANCE LISPED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION Of ANY CONTRACT OR OTHER DOCUM -'-NT VNTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED SY TIS POLICI> $ DESCRIBED HER N IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS, LTR TYPEGPINSURANCE POLICYNUMBER P L L1MiTa A $ COMMERCIAL GENERAL LaABILITY CLAIMS -MADE OCCUR f . 'CA `— 01CIB8B076d1 2/17/2617 '2/17/¢0i8 EACH OGURRENCE 1,044,440 FREMISg 200,000 MED Ex � Any oneperson) 5 14,,404 [3EN'L AW4REQATE LIMIT APPLIES PER: POLICY ❑ J r O L00 Fi , PERSOP IL8ADV INJURY s 1,000,000 GENE AGGREGATE T _ 2,000,000 PROGU 8-COMPlOPA4G * 2,000,004 EmrA Ara' sea LIab Ins $ 10,000 AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED ALITCe AUTOS AUTr8 AUTG9NON-OWNED I I ILY I i1JURY (Per pelacn) I :RRCF ILYI JURY(Perecalftnt)Nlf#ED ER DAMAGE 1 $ UM9RELLALIAO H EXCE88 LIAO OCCUR CLAIMS -MADE EACH OCCURRENCE AGGiiE TE $ It B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETDPJPARTNERlEXCCUTIVE YIN OFFICERIMEMBEREXCLUDED7 (Mandatary in NH) Ras daacrlbs under MIAT ERATICNS btlm+ NIA 1 NC3C91463668035 13/9./9016 12/1/2017 I PER E.L. EAC ACCIDENT $ 11000 ,000 E . 01311 k8r- EA EMPLOYEE $ 1,000,000 re -4, OI3 R • POLICY LIMIT $ 2400,000 DE6CRIPTIGN OF OPERAT10N61 LOCATIONS i VEHICLES (ACORN 109, Additlarial ReMarka Sehedvte, maybe attached Ir more apace Is required) Ra: Zv:Ldarica at Inaurancia a RM - SHOULD ANY OF THE ABOVE DE; Cantrallators State License Beard T14E EXPIRATION DATI3 THEFT PO Sox 26000 ACCORDANceWITH THE 'PoLICY Sacrazant0, CA 95826 AUTROR12F,p REPRESENTATIVE Eames Hunt/CRA (D1998-2014 AC01 ACOR,D 25 (2014101) The AC ORD name and logo are registered marks of ACORD INS0251901401) POLICIES BE CANCEILLED BEFORE )TICE WILL BE DELIVERED IN reserved.