B-2017-2197CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR.
PERMIT NO: B-2017-2197
20336 NORTHBROOK SQ CUPERTINO, CA 95014-0566 (316 39 013)
F W H ACQUISITION
CO LLC
BOTHELL, WA 98011
OWNER'S NAME: LEE YAU-SHING AND KUO FANG -YIN WENDY TRUSTE
DATE ISSUED: 12/21/2017
OWNER'S PHONE. 408-750-6160
PHONE NO: (425) 636-7084
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO -
License Class C36 Lic. #987398
Contractor F W H ACQUISITION CO LLC Date 10/31/2019
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 HEATER (SAME LOCATION)
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
Compensation, as provided for by Section 3700 of the Labor Code, for the
rN performance of the work for which this permit is issued.
2. 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. $1380.04
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
APN Number-
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
and state laws relating to building construction, and hereby authorize
316 39 013
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.
Additionally, the applicant understands and will comply with all non -point
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cupertino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION
ivo
Signature V Date 12/21/2017
Issued by- AbbLyende
Date: 12/21/2017
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
inspection.
sale (Sec.7044, Business & Professions Code)
z. I, as owner of the property, am exclusively contracting with licensed
Signature ofApplicant:
contractors to construct the project (Sce.7044, Business & Professions Code).
Date: 12/21/2017
I hereby affirm under penalty of perjury one of the following three declarations:
t. I have and will maintain a Certificate of Consent to self -insure for Worker's
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
-
j
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 DISCLOSUKt
z. 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,
ind 25534. I will
permit is issued.
maintain compliance with the Cupertino Municipal Code, C
hapter 9.12 and the
a. I certify that in the performance of the work for which this permit is issued, I
Health & Safety Code, Section 25532(a) should 1 store or
landle hazardous
shall not employ any person in any manner so as to become subject to the
material. Additionally, should I use equipment or devices w
ich emit hazardous
air contaminants as defined by the Bay Area Air Quality Mi,
nagement 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, Se ions 25505, 25533,�nd
25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked. �
--
Owner or authorized agent:
`
APPLICANT CERTIFICATION
Date: 12/21/2017
I certify 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
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.
for
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.
Signature Date 12/21/2017
Licensed
Professional
111237
GENERAL PERMIT APPLICATION
C0141MUNITY DEVELOP14ENT DEPARTMENT SUILDJNG D!V1,S10tq MEP
10300TORREAVENUE CUPERTIhJft,C'k9-501
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(408,'1 777-3228 FAX (408) 777-3333 . t uiit- sLrL ri+r.or,
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