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B-2017-0464CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0464 1038 NOVEMBER DR CUPERTINO, CA 95014-4123 (362 15 003) F W H ACQUISITION CO LLC BOTHELL, WA 98011 OWNER'S NAME: ZHANG MINHUI AND MEIDING OWNER'S PHONE: 408-660-6908 LICENSED CONTRACTOR'S DECLARATION License Class C-36 Lic. #987398 Contractor F W H ACQUISITION CO LLC Date 10/31/2017 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 license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: i. I have and will maintain a certificate of consent to self -insure for Worker's ISSUED: 03/22/2017 NO: (425) 636-7078 PERMIT INFO: X BLDG —ELECT X PLUMB _ MECH X RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: REPLACE (50 GAL) WATER HEATER - SAME LOCATION - GARAGE 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: $1360.00 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 and state laws relating to building construction, and hereby authorize 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 may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature / Date 03-22-2017 OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: i. I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) 2. I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). "N Number: Occupancy Type: 362 15 003 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: Kim Dunbar RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without fust obtaining an inspection, I agree to remove all new materials for inspection. Signature ofApplicant: Date: 03-22-2017 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. 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. 3. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. 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 and state laws relating to building construction, and hereby authorize 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 may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date 03-22-2017 HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owner or authorized agent: Date: 03-22-2017 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DF,C.'_I.ARATTON I understand my plans shall be used as public records. Licensed Professional CUPERTINO COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building0aDcupertino.org VtLLWBING I (MECHANICAL 7F.T.FCTRTC..AT. n crP A C)TTQ PROJECT ADDRESS t A Q ©ju ' - �— _rte 3 APN # z—_ /5,--()C) /E-MAIL OWT ER NAME s.h , �\ /► �l PHO'. 0 p��9 i STREET ADDRESS f ,s �J� CITY, STATE, ZIP FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER ❑ OwNER-BUII,DER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME (� , i LICENSE NU�QB� LICENSE kTYPE BUS. LIQ #q ' T e"� V/ COMPANY NAME E-MAIL{/ FAX STREET ADDRESS K ^'� V\� VLIVCEPdSE CITY, STATE, ZIP �1i P n 1 OltV (}� \/ V � I PHONE /( /j t- 9 �► -r ARCHITECT/ENGINEER NAME NUMBER BITS. LIC COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF IVSFDorDUPLEX El MUT-TI-F AM IL}' BUILDING: ❑ COMMERCIAL. PROJECT IN WILDLAND [1 YES URBAN INTERFACE AREA El No PROJECT IN ❑YES FLOOD ZONE ElNO IS THE BLDG AN ❑ 1B5 EICHLER HOME? 171NO DESCRIPTION OF WORK J� \ TOTAL VALUATION: DBY By my signature below, I certify to each of the following: I am the property owner or authorized agent to ac 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 )ATork and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buildm' truction. I authorize representatives of Cupertino to enter the above -identified propejfor inspection purposes. Signature of Applicant/Agent: 1/C Date:' SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY . ' Ol ER-TITE GOUATER - °- f" ❑ EX_ PRE_ SS- U - ..STANDARD 4 LARGE ❑ MAJOR MEPMiscA4pp_2011.doe revised 06121/11 71 U.'./ G (/ GUl ( MUN 11: 44 FAX FaLat Walter He Li�OY U002/002 ACOPROF. CERTIFICATE OF LIABILITY INSURANCE DAT Ii(MMJDDtYYYY, TYPE OF INSURA!: 1118/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS 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 OANTRAOT BETWEEN THE ISSUING INSURER(S), AUTHORIZED . REPR"ENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT. If the certificate holder Is an ADDITIONAL INSURED, the polley(les) must be ando med. If SUBROGATION IS WAIVED, subject to the terms and conditions of the Policy, certain policies may require an andorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsament(s . PRODUC@RN_cO 8 71 Anderson Agrancy, Ino; SOD Sw 39th st, Suite 200 NE Kat.lYy H4?W� LtI1d a (425) 291-5200 FAX (�26)FB1�6140 M kat Aon ESS hlrhSball-andara4a.aom INSURERUS APFORDIND COVERAG@ NAIC / Itentari WA 98057 INSURERAAmarioan States Inauranco Conpany 19704 INSURED FM IACluisitlan Do LLC, D3,&I Fast WD %ter Keatg.r Co 11715 NOi th Creek Parkavay - s #C-106 INSURER I9;LibBrtV Mutual Fira InA;Urar l;a 23025 INflURERC: INSURER D INSURER E Sa�tha311 WA 98x7 7 INSURER P 1'11. Y1411./IY IV VIYI L]GISi THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR Ct DITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THI$ CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED 13Y THE POLIOMS DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, LTR TYPE OF INSURA!: POLICY NUMBER r` P L LLMITa A X COMMERCIAL GENERA CCIJ19BR TTY "� CLAIMS -MADE OCCUR r » � � t)SCF68BOs rT- •i 2/17j2D-1Ty /2b?3==MEDEXP(An EACH OCCURRENCE 1,000,000 Misog 200,000 ons aeon) 10,000 PERSONAL & ADV INJURY S 1,000,000 UEN'L A417REOATE LIMIT APFLIE6 PER: POLICY E jT 1:1 LOG FI OENERAL AGGRE3AATE S 2,000,000 PRGOUGYa9-GGMPlIit'AGO $ 2r000r40+3 Empl Practises Laab Ins $ 10,000 AUTOMOBILE LIABILITY ANY AUTO AUTOU ED AUTOS HIREDAUTOS NON.OWPIRD AUT�a6 eIqGLff LIMIT ffi == BODILY INJURY (Forpelaort) S BODILY INJURY(Par000ldonl) $ PROPERT"AW OE $ $ UMBRELLA LIAR 6XC:ESS LIAO OCCUR CLAIMS -MADE EACH OCCURRENCE AGGREGATE $ l ffi $ WORKERS COMPENSATION AND EMPLOYERS'LIANILITY YIN ANY PROPRIETOMPARTNEWEXECUTIVE 0 OFFICERIMEM13ER EXCLUDED? (Mandataryln NH) Ir es IPTnbe under ERATIONS Wow NIA 1 W=91464663026 12/1/2016 18/7./2017 PER 151. EACH ACCIDENT S 11000,000 G.L. DiaMOSE - EA EMPLOYE $ _ 1,000,000 E.I., DISEASE. POLICY LIMIT $ 1 O00 000 JI - I I %. CEOCRIPTIDN OF OPERATIONS f LOCATIONS I VEHICLES (ACORO 101, Additional Remarks Schedule, may he attached if more space Is required) Liao: ILvidanaa of Insuranaa a e ilk m=il faastwatarheater . c Contra dors State Licenae Board PO Box 2£I000 Smaranonta, CA 95826 SHOULD ANY OF THE AaOVG DESCRIB4111 POLICIES 99 CANCNLLrID RNFORS TI48 EXPIRATION DATE THEREOF, NOTIGM WILL BE DELIVERED IN AGGORDANGE WITH THE P4LlGY FIROVISIIONS. REPRE0ZNTATIYI; Tames Hunt/CIRIA 19BB-2014ACORD CORPORATION. All flahts reserved. ACORD 26 (2014/01) The ACORD name and logs are registered marks of ACORD INS1525 rar,IdlS+� CUPERTINO SMOKE / CARBON MONOXIDE ALARMS OWNER CERTIFICATE OF COMPLIANCE COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(Qcupertino.org PERMIT CANNOT BE F'INALED"UNTIL THIS CERTIFICATE HAS BEEN COMPLETED, SIGNED. D AND IEXURM TO THE BUILDING DIVISION PURPOSE This affidavit is a self -certification for the installation of all required Smoke and Carbon Monoxide Alarms for compliance with 2016 CRC Section R314, R315, 2016 CBC Sections 420.6 and 907.2.11.2 where no interior access for inspections are required. GENERAL INFORMATION Existing single-family; and multi -family dwellings shall be provided frith Smoke Alarms and Carbon Monoxide alarms. When the valuation of additions, alterations, or repairs to existing dwelling units exceeds $1000.00, CRC Section R314, R315, and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and/or Carbon Monoxide Alarms be installed in the following locations: AREA SMOKE ALARM CO ALARM Outside of each separate sleeping area in the immediate vicinity of the bedroom(s) - (Smoke alarms shall not be located within 3 feet of bathroom door) X X On every level of a dwelling unit including basements and habitable attics X X Within each sleeping room I ' . . I IX Carbon Monoxide alarms are not required in .dwellings which do not contain fuel -burning appliances and that do not have an attached garage. Carbon.monoxide alarms combined with smoke alarms shall comply with CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal. Power Supply: In dwelling units with no commercial power supply, alarm(s) may be solely battery operated. In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do not result in the removal of wall and ceiling finishes or there is no access by means of attic, basement or crawl space. Refer. to CRC Section R314 and CSC Sections 907.2.11.4 and 420.6.2. An electrical permit is required for alarms which must be connected to the building wiring. As owner of the above -referenced property, I hereby certify that the alarm(s) referenced above has/have been installed in accordance with the manufacturer's instructions and in compliance with the California Building and California Residential Codes. The alarms specified below have been tested and are operational, as of the date signed below. Address: a,- Permit No. Specify Number of Alarms: # Smoke Alarms: F7_1 # Carbon Monoxide Detectors: I have read and agree to comply with the terms and conditions of this statement Owner (or Owner Agent's) Name: Sinature.............................................................................. Date:............... _ Contractor Name: Signature...................................................................... Lic.#........................................ Date:................... Smoke and CO form.doe revised 0111012017 Owner Name Address WATER -CONSERVING PLUMBING FIXTURES OWNER CERTIFICATE OF COMPLIANCE COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-322 •r'iF (408) 777-3333 • buildingCcDcupertino.org /i i P�(--�fAI ��719 Permit No. �J -�� ® 0 1Ll14 /oye61_ Vr- (kofino e (-4 9ro( 1. Is your real property a registered historical site? ❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. No Go to Question 2. 2. Does your real property have a licensed plumber certifying that, due to the age'or configuration of the property or its plumbing, installation of water -conserving plumbing fixtures is not technically feasible? ❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. ❑ The licensed plumber's certification has been provided to the Building Division. Skip the rest of the form and sign bottom of form. - ril No Go to Question 3. 3. Is water service permanently disconnected for your building? ❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. No Go to Question 4. 4. Is your real property built and available for use or occupancy on or before January 1, 1994? ❑ No My real property is built and available for use or occupancy after January 1, 1994. Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. Yes My real property is built and available for use or occupancy on or before January 1, 1994. Civil Code Sections 1101.1 through 1101.8 apply. Check one of the three following statements and sign bottom of form.. 5. Please check ONE of the following: My property is a single, family residential real property. See Civil Code Section 1101.4. / \ On and after January 1, 2014, building alterations or improvements shall require all non-compliant plumbing fixtures to be replaced with water -conserving plumbing fixtures throughout the building. On or before January 1, 2017, all non- compliant plumbing fixtures shall be replaced with water -conserving plumbing fixtures (regardless of whether property undergoes alterations or improvements), ❑ My property is a multifamily residential real property. See Civil Code Section 1101.5. On and after January 1, 2014, specified building alterations or improvements shall require non- compliant plumbing fixtures to be replaced with water -conserving plumbing fixtures. On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water - conserving plumbing fixtures throughout the building (regardless of whether property undergoes alterations or improvements). ❑ My property is a commercial real property. See Civil Code Section 1101.5. On and after January 1, 2014, specified building ialterations or improvements shall require non- compliant plumbing fixtures to be replaced with water -conserving plumbing fixtures. On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water- conserving plumbing fixtures throughout the building (regardless of whether property undergoes alterations or improvements). I, as the owner or owner's agent of this property, certify under penalty of perjury that non-compliant plumbing fixtures will be replaced prior to date specified above with water -conserving plumbing fixtures in accordance with Civil Code Sections 1101.1 through 1101.8, the current California Plumbing Code and California Green Building Standards Code, and manufacturer's installation requirements, and that the water -conserving plumbing fixtures comply with the requirements as indicated in the table on the following Dage. _--n„ _ ----) _ Owner or Owner Agent's Signature: r' Dater ► Upon completing and signing this Certificate, please return it to the Building Division in order to final your building permit. SB407 2015. doc revised 01/05117