B-2018-1381 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMITNO:B-2018-1381
21470 COLUMBUS AVE CUPERTINO,CA 95014-4971(362 05 002) F W H ACQUISITION
CO LLC
BOTHELL,WA 98011
OWNER'S NAME: DATE ISSUED:08/15/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO;
License Class C36 Lic.#287-398
Contractor F W H ACQUISITION CO LLC Date 10/31/2019 X BLDG_ELECT X PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing —MECH X RESIDETAL_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code mrd that my
license is in fill force and effect. SOB DESCRIPTION:
REPLACE 50 GAL WATER HEATER(SAME LOCATION)
I hereby affirm under penalty of perjury one of the following two declarations:
v 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
,
have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the perfornnaace of the work for which this
permit is issued. Sq.Ft Floor Area; Valuatfon:$1550.47
APPLICANT 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 APNNumber: Occupancy Type:
and slate laws relating to building construction,and hereby authorize 362 05 002
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 B-15-2018 Issued by:Kim Donlon
Date:QSM2018
OWNER-BUILDER DECLARATION
I hereby affirm that tam exempt from the Contractor's License Law for one of the 12E-ROOFS:
following two rea—rs: All roofs shall be inspected prior to any roofing material being installed.If a roof is
r. I,as owner Of the property,army employees with wages as their sole installed 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 mspcctdr.
sale(Sec.7044,Business&Professions Code)
z. Las owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:8-15-2018
1 hereby affirm under penalty of perjury one of tine following 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 Workers
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 Insuraoce,as provided for by 1 have read Bre hazardous materials requirements tinder Chapter 6.95 of the
Section 3700 of the Labor Code,fur the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534.1 will
permit is Issued. moimatn compliance with the Cupertino Municipal Code,Chapter 9.12 and tine
s. 1 certifythat in the performance of the work for which this t is issued,I Health&Safety Code,Section 25532(x)should I store ur handle hazardous
p` pone material.Additionally,should I use equipment or devices which emit hazardous
shall not employ m,y person in any manner so as[o become subject to the air contaminants as def7ned by the Bay Area Air Quality Management District I
Worker's Compensation laws of California.If,after nuking this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,1 become subject to the Worker's Compensation provisions of the the Health&Safety Code,
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 Date 8-15-2018 professional