B-2017-1083CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-1083
21818 LOMITA AVE CUPERTINO, CA 95014-2830 (357 15 107) F W H ACQUISITION
CO LLC
BOTHELL, WA 98011
OWNER'S NAME: CHELIDZE NATELA V AND YUTSIS VLADIMIR
DATE ISSUED: 07/07/2017
OWNER'S PHONE: 408-865-0243 I I PHONE NO: (425) 636-7078
IN Irii nki Di 1X4113 r r maw 1191-Al`l]1Iy �\t7_\ rrrLy
License Class PLUMBING 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:
t. I have and will maintain a certificate of consent to self -insure for Worker's
BUILDING PERMIT INFO:
X BLDG —ELECT X PLUMB
_ MECH $ RESIDENTIAL _ COMMERCIAL
DESCRIPTION:
,ACE 50 GAL WATER HEATER
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: $1857.46
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 V.
/ \v,C,A"(J\ Date 7/7/201.7
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
t. 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).
APN Number: Occupancy Type:
357 15 107
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: Abby yende
Date: 07/07/2017
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature ofA1
Date: 7!7/2017
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF
r. 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/77 /2017
" OR BETTER
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 mamt 'n compliance with the Cupertino Municipal Code, Chapter 9.12 and
j.A3vHealth & Safety Code, Sections 25505, 25533, and 25534.
Owner or authorized agent:
Date: 7/7/2017
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 DECLARATION
understand my plans shall be used as public records.
Licensed
Professional
07/03/2017 MON 14:56 FAX Faai: water Heater
FTM
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GENERAL PERMIT APPLICATION
COKWUNITY DEVELOPLiENT' DEPARTIJVENT • BUILDING DIVISION
10304 TORRE AVENUE - CUPkRTINO. CA 85014-3251
CUP 6R f I NO (408) 777-3228 • FAX {448) 777.3333 -bull - n 0g.o(u
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CITY, XIATh,ZIP CUPERTINO CA 95014
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rONTACT 1IAML Katy Kehle FAST Water Heater
425-636-7084
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V-CTADDRISS 11715 N Creek Pkwy S, C-106
CITY•STATE, zIP Bothell WA 98011
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City, srATu, rlr Bothell WA 98011
PHONE425-636-7084
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SUPPLEMENTAL INFORMATION REQUIRED
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