B-2018-0913 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0913
21745 ALCAZARAVE CUPERTINO,CA 95014-5929(357 19 111) F W H ACQUISITION
CO LLC
BOTHELL,WA 98011
OWNER'S NAME: DATE ISSUED:05/29/2018
OWNER'S PHONE: PHONE NU:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C36 U.,#987398
Contractor F W H ACQUISITION CO LLC Date 10131/2019 X BLDG—ELECT X PLUMB
I hereby affirm that I am licensed tinder 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 fn full farce and effect. JOB DESCRIPTION:
(N)50 GAL WATER HEATER-SAME LOCATION
I hereby affirm under penalty of perjury one of the following five 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
performance of the work for which this permit is issued.
threeand will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work Por which this
permit is issued. Sq.Pt Floor Arca: Valuation:$2141.27
AYPLIGANT 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: O—Liturey'fype:
and state laws relating to building construction,and hereby authorize 357 l9 III
representatives of this city to enter upon the above mentioned property far
inspection purposes. (We)agree to save indemnify and keep harmless the
City of Cupertino against liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORI{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 tha G;gino Municipal Code,Section 9.18, 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 05/29/2018 Issued by:Jasmine Archbold
Date:05/29/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Confit actor's License Law to].one of the RE-ROOFS,
following two reasons: All roofs sholl be inspected prior to any roofing moterin]being installed.Ira roof is
r. 1,as owner of the property,or my employees with wages as their sole installed without first obtaining a,,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(Se.7044,Business&Professions Code)
z I,as owner of the property,am exclusively contracting with licensed Signature ofApplicanu
camractars to construct the project(Sec.7044,Business&Professions Code). Date:05/29/2018
I hereby affirm under penalty of perjury one of[he following three declarations: ALL 1200P COVERINGS TO BE CLASS"A"OR BETTER
r. 1 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 ofthe work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. 1 have and will maintain Worker's Compensation Insurance,as provided for by I have read the haxm dour materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the peifarmance of the work far which this California Health&Safety Corlc,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,l r Hmtlth&Safety Code,Section 25532(x)should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the material.Additfonally,should 1 use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District 1
Woker's Compensation laws of California.If,alter making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I became subject to the Worker's Compensation provisions of the the Health&Safety Code,Starton2s1 FSq�tf25533,and 25534.
Labor Code,1 must forthwith comply with such provisions or this permit shall �"`
APP
his LICANT CERTIFICATION Date:05/29/2018
I certify that I have read tapplication and State thlicaat 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 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 Al2CH1'I'EC'VS DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Date 05129/2018 Licensed
Professional