B-2018-1095 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1095
7941 OCTOBER WAY CUPERTINO,CA 95014-4124(362 12 028) F W H ACQUISITION
CO LLC
BOTHELL,WA 98011
OWNER'SNAME:Cheng Ming And Xie Yongjin DATE ISSUED:06/28/2018
OWNER'S PHONE: PHONE No:(425)636-7080
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C36 Up.#987398
Contractor F W H ACQUISITION CO LLC Date 1 0131/2 01 9 X BLDG—ELECT X PLUMB
1 hereby affirm that 1 nm 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 tinder penalty of perjury one of the following two declarations:
1. 1 have and will maintain a certificate of consent to self-insure for Worker's
z 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 At Valuation:$1645.69
APPLICANT CERTIFICATION
I certify that I have read this epplicatlon 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 362 12 028
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 WORT{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 p 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 affirm that I am exempt from the Contractor's License Law fa.one of the RE-ROOFS:
following t—reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
r. 1,as owner of the property,or my employees with wages as their sole installed without Prst obtaining on inspection,1 agree to reprove all new materials for
compensation,will do the work,and the structure is not intended or offered far inspection.
sale(Sec.7044,Business&Professions Code)
I,as owner o£the property,am exclusively contracting with licensed Signature ofApplicant:
contractors to construct the project(Sec.7044,Business&Professions Cade). ate: 8
1 hereby affirm under penalty of perjury one of Cite following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
C. 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
z. I have and will maintain Worker's Compensation Insurance,as provided fmby 1 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,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,I t Health&Safety Code,Section 25532m)should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the air ate rial.Additfonnlly,should I use equipment at,devices which emit hazardous
ontaminants its defined by the Bay Area Air Quality Management 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 became subject to the Worker's Compensation provisions of the the Health&Safety Code,eons 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
APPLICANT CERTIFICATION Date:0 612 81201 8
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 ARITECT'S DECLARATION
Code,Section 9.18.
on my plans shaCHll be used as public records.
Signature Data 06/28!2018 Llcensed
Professional