B-2016-2198 CITY O CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2198
1040 TUSCANY PL CUPERTINO,CA 95014-4352(359 29 040 F W H ACQUISITION
CO LLC
BOTHELL,WA 98011
OWNER'S NAME: SCOTT APRIL L TRUSTEE DATE ISSUED:06/23/2016
OWNER'S PHONE: PHONE NO:(425)636-7078
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class PLUMBING Lic.#987398
Contractor F W H ACQUISITION CO LLC Date 10/31/2017 X BLDG —ELECT—PLUMB
I hereby affirm that i am licensed under the provisions of Cha ter 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:
REMOVE/REPLACE 40 GALLON WATER HEATER
I hereby affirm under penalty of perjury one of the following Iwo declarations:
t. 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 issue
2. I have and will maintain Worker's Compensation Insur nce,as provided for by
Section 3700 of the Labor Code,for the performance o the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$1195.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the agave
information is correct.I agree to comply with all city and cou�Itty ordinances APN Number: Occupancy Type:
and state laws relating to building construction,and hereby Authorize 359 29 040
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We)agree to save indemnify and kee harmless the
City of Cupertino against liabilities,judgments,costs,and ex 3enses 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,Sectio 19.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date Issued by:Patricia Garcia
Date:06/23/2016
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's Licens Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.if a roof is
t. I,as owner of the property,or my employees with wage 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 inspection.
sale(Sec.7044,Business&Professions Code)
2. 1,as owner of the property,ani exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business Professions Code). Date:
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
2. I have and will maintain a Certificate of Consent to self insure for Worker's
Compensation,as provided for by Section 3700 of the bor Code,for the
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insure ice,as provided for by I 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
3. I certify that in the performance of the work for which t1 is permit is issued,I Health&Safety Code,Section 25532(x)should I store or handle hazardous
material.Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the
J air contaminants as 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 become subject to the Worker's Compensa�'on provisions of the the Health&Safety Code,Sections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provi: or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:
I certify that I have read this application and state that the abo a information is CONSTRUCTION LENDING AGENCY
correct.I agree to comply with all city and county ordinances'nd state laws I hereby affirm that there is a construction lending agency for the performance
relating to building construction,and hereby authorize repres ntatives 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 pu poses. (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 sid City in Lender's Address
consequence of the granting of this permit. Additionally,the a�plicant 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 Professional
06/23/2016 THU 8- 11 FAX Fab-1; water Heater [[ U002/002
GENERAL PERMIT APPLICATION �J
MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION /�8
10300 TORRE AVENUE,-CUPERTINO, CA 95014-3255 J?il``�Z
(408)777-3228-FAX(408)777-3333-I2iLdfntt(Mcu�a inO.ora ,��•� M',�
CUPERTINO. .• • �>' `'
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PLUMBING MECHA ICAL ELECTPICAL MISCELLANEOUS
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OWNER NAKM 1 y 1 PHONE C-MAIL ,
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CONTACT NAME ryj PH
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STREET ADDRESS CITY,STATE,ZIP J / PAX
n OWNeK ❑ OWNER•BUILDBR ❑ OWNERAGBNT *I PNTRACrOR ❑cowixACTORAGBNT ❑ ARCIETECT 0BNGIM11P ❑ DBVELOPER ❑TENANT
CONTRACTOR NAME r1 r_..O _e �w�,_• LICENSO NUMBER C C LICENSE T J_ BUS.LIC 11
COMPANY NAME F-A A , JQ4a_ , E'1Ein PdSf W&4, rL Qo(h �yxc,Z. —bt�i66'1' pv_
STREET ADDRESS [Fl l I r STAB,Z P PHONE 3/ — ?o �C
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ARCHITECT/ENOMKt R NAME LICENSE NUMBER BUS,LIC A t0 J
COMPANY NAME B.MAIL PAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF SPU a,DUPLEX ❑ MULTI•TAMILY PROMCTIIN WILDLAND ❑ YES PROTECT IN ❑YES IS 7FIB BLDG AN ❑Yes
BUILDING: [3 COMMERCIAL URBANINT13RFACEAREA ❑ NO FLOOD ZONE ❑NO EICriLERttOMG9 ❑NO
DESCRIP'TtON OF woRQ�Lmhoj
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TOTAL.VALUATION: ` QLJ �C{ � ,�..I.•!�),�4��{°�.!����; e;bll•i!y '���•`11�I1,����yl•IZI!\�til•.,.S��p�
By my signature below,I certify to each of the following: I am the properly owner or authorized agent to eat on the property owner's behalf. 1 have read this'
application and the information 1 have providcd is correct. I have dead the Descl•iption or Work and verify It Is accurate, I agree to comply with all applicable local
ordinances and state laws relating to buildin construction I authorize representatives of Cupertino to enter the above-identi red property for inspection purposes,
Signature of Appl icant/Agent: C'��` Date; (_0
SUPPLEMENTAL INFO[iM TION REQUIRED
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MEPN/iscApp2011.doc revised 46/21/11
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