B-2018-1247 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1247
21044 HAZELBROOK DR CUPERTINO,CA 95014-1629(32655034) FW HACQUISITION
CO LLC
BOTHELL,WA 98011
OWNER'S NAME: DATE ISSUED:07/25/2018
OWNER'S PHONE: PHONE NO:(425)636-7080
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C36 Lin.#987398
Contractor F W H ACQUISITION CO LLC Date 10/31/2019 X BLDG ELECT X PLUMB
I hereby affirm that I am licensed ander 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)
1 hereby affirm under penalty of perjury one ofthe following two declarations:
r. I have and will maintain a certificate ofeonsent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Lobor Code,far the
„ performance of the work for which this permit is issued.
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: Vsduadon:$1542.19
APPLICANT CERTIFICATION
I certify that I have read this appllcallon and state that the above --
information is correct.I agree to comply with all city and county ordinances APN Number: Occupancy Type:
1 and state laws relating to building construction,and hereby authorize 326 55 034
representatives of this city to enter upon the above mentioned property for
wN a inspection purposes. (We)agree to save indemnify and keep harmless the
'?'Gity 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
soutce regulations per the Cupertino Municipal Code,Section 9.18. ISO DAYS FROM LAST CALLED INSPECTION.
Signature — Date 7-26-2018 Issued by:Kim Dunbar
Date:07/25/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RF ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.He roof is
r. 1,as owner ofthe property,or my employees with wages as their sole inatured without first obtaining an inspection,I agree to remove all new materials for
ompensetio a will do the work,and the structure is not intended or offered for inspection.
sale(Sce.7044,Business&Professions Code)
x. 1,as owner ofthe property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:7-25-2018
I hereby affirm under penalty of perjury one of the fallowing three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
u I have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 ofthe Labor Code,For the
_. performance ofthe work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
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 ofthe 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 Bre
s. I certify that in the performance ofthe work for which this permit is issued,i Health&Safety Code,Section 25532(a)should 1 store or handle hazardous
shall not em to an to become subject to the naterial.Additionally,should I use ca idi mmnt or devices which emit hazardous
p y y person in any manner so as J r contaminants as defined by the Bay Area Nr Quality Management District I
Worker's Compensation laws of Califendo.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 ofthe the Health&Safety Code,Sections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:7-25-2018
1 certify that I have read this application and stale that the above Information is I 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 Ilabilities,
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 Date 7-25-2018 Professional