B-2018-0772 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0772
10207 CAMBERLEY LN CUPERTINO,CA 95014-2632(342 42 028) F W H ACQUISITION
CO LLC
BOTHELL,WA 98011
OWNER'S NAME: DATE ISSUED:05/07/2018
OWNER'S PHONE: PHONE NO:(425)636-7080
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class CC36 Lic.#987398
Contractor E W H ACQUISITION CO LLC Dale 10/31/2019 X BLDG ELECT X PLUMB
I herebyaffirm that I am licensed under the _MECH X RESIDENTIAL_COMMERCIAL
a provisions of Chnpter 9(commencing
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is fn 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:
r. I have and will mainmiu a certificate of consent to self-insure for Worker's
Compensation,as in 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
v permit is issued. Sq.Ft Fluor Are.: Vnlmuimu$1800.00
APPLICANT CanERTIFICATION
I certify that I have read this application d state that the above
information Is correct.I agree to comply with all city and county ordinances APN Number: Occupancy Type:
and slate laws relating to building construction,and hereby authorize 342 42 028
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 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 the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature ' Date 05-07-2018 Issued by:Kim Dunbar
Date:0/07/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of theRE-ROOFS:
following two reasons: All roofs shall be inspected prior to any rooting material being installed Ha roof is
r. 1,as owner of the property,or my employees with wages as their sole instilled 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(See.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant
contractors to construct the project(Sec.7044,Business&Professions Cade), Date:05-07-2018
I hereby affirm under penalty Df perjury one of the following three dechtrations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
-
Compensation,
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 MATERIALS DISCLOSURE
I, I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous matin lots requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which thisCnlifurniu.Health&Safety Code,Sections 25505,25533,and 25534.I will
permit is issued. toalit compliance with the Cupertino Municipal Code,Chapter 9.12 and the
a. I certify that in the performance ofthe work for which this permit is issued,I Health&Safely Cede,Section 25532(a)should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the material.Additionally,should I use equipment or devices which craft hazm dnus
contaminants as defined by the Bay Area Ali-Quality Management District 1
Worker's Compensation laws ofCali£ornia.If,after making this certificate of will maintain compliance with the Cupertino N,jmodpal Code,Chapter 9.12 and
emption,I become subject to the Worker's Compensation provisions of the the health&Safety Cade,Sectio�s�'Sr505,25533,and 25534.
Labor Code,l must forthwith comply with such provisions or this permit shall
APPLICANT CER'T'IFICATION Date:05-07-2018
1 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 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 ARCIH'II"S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date 05-07-2018 professional