B-2018-1093 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1093
10445 SAN FERNANDO AVE CUPERTINO,CA 95014-2834(357 12 050) F W H ACQUISITION
CO LLC
BOTHELL,WA 98011
OWNER'SNAME:Qian Kun And Lin Yuegin DATE ISSUED:06/28/2018
OWNER'S PHONE: PHONE NO:(425)636-7080
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class 03_a I.E.#987398
Contractor F W H ACQUISITION CO LLC Date 10/3112019 X BLDG ELECT X PLUMB
1 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:
(N)50 GAL WATER HEATER-SAME LOCATION
I hereby affirm under penalty of perjury one of the following two declarations:
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 Cade,for the
performance of the work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as in to,by
VSection 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Flnur Arca: Valuation:,$2152.84
APPLICANT CERTIFICATION
I certify that I have read this appllcalion and state that the above
information is correct.I agree to comply with all city and county ordinances APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 357 12 050
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. 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 06/28/2018 Issued by:Jasmine Archbold
Date:06/28/2018
OWNER-BUILDER DECLARATION
I hereby aftlrm that I am exempt from the Contractor's License Law for one of Line HE'ROOFS:
following two reasons: All roofs shall be inspected prior to any...frE material being installed He of is
1. 1,as owner ofthe property,or my employees with wages as their sale installed without first obtaining an inspection,I agree to remove all new materials for
ampere atian,will do the work,and the structure kind intended or offered for inspection,
aale(Sec.7044,Business&Professions Cade)
z. I,as owner of the property,am exclusively contracting with licensed Signature ofApplicauC
�mmactors to construct v projec Sec7044,Emat`ess&-1 rote imide. Dan-46/28/2018
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, HAZARDOUS MATERIALS DISCLOSURE
i. 1 have and will maintain Worker's Compensation Insurance,as provided far by I have read the hazardous.archils 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,and 25534.1 will
permit is issued. m aintaln compliance with the Cupertino Municipal Code,Chapter 9,12 and the
e. 1 certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(x)should I store or handle hazardous
shall not employ person in material.Additionally,should I use equipment or devices which emit hazardous
p y any y manner so as to become subject the contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation
an n laws of California.If,offer making this certificate of wnr ill maintain coaplhmce with the Cupertino Mmucipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sns 25505,25533,and 25534.
Labor Cade,l must forthwith comply with such provisions or this permit shall
APPLICANT CERTIFICATION Date:06128/2018
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 ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Data 0012812018
Professional