B-2016-1747CITE' OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-1747
11511 WELL SPRING CT CUPERTINO, CA 95014-5136 (366 51 039)
F W H ACQUISITION
CO LLC
BOTHELL, WA 98011
OWNER'S NAME: DAVID LAND SHIRLEY DEH -LI TRUSTEE BATES
DATE ISSUED: 04/13/2016
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
MECH X RESIDENTIAL COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
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 GAS WATER HEATER 50 GAL
I hereby affirm under penalty of perjury one of the following two declarations:
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.
2. 1 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
Sq. Ft Floor Area:
Valuation: $1310.00
permit is issued.
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
APN Number:
Occupancy Type:
and state laws relating to building construction, and hereby authorize
366 51 039
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 WORD IS NOT STARTED
may accrue against said City in consequence of the granting of this permit.
WITHIN 180 DABS ®F PERMIT ISSUANCE ®R
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
Issued by: Patricia Garcia
Date: 04/13/2016
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License 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
1. I, as owner of the property, or my 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
inspection.
sale (Sec.7044, Business & Professions Code)
2. I, as owner of the property, am 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
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
2. 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 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 this permit is issued, I
Health & Safety Code, Section 25532(a) should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the
material. Additionally, should I use equipment or devices which emit hazardous
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 Compensation provisions of the
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:
I 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 Date
Professional
04/11/2016 MON 7242 FAX FaLSt Waiter HeaLteY 14r,1vuz/ vv,;
)
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CVPERTI '0 (409) 777-3228 - FAX (408) 777-3333 • build ing(a1cuoertino.ora �p —�M I S C�
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PROTECT ADDRES
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STREET ADDRESS
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❑ OWNER ❑ OWNER-piumo R ❑ OWNER AGENT
XCONTRACrOK ❑CONTRACTORAGENT ❑ ARCHITECT ❑ ENOINEBR ❑ DEVELOPER ❑ TENANT
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LICENSE NUMBER col � ��777—
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STREET ADD
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ARCHITPUMNOINEEK NAME
LICENSE NUMBER
BUS. LIC f!
COMPANY NAME
Lr -MAIL
PAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF SFD ;UPL13X ❑ MUI:rI-FAMILY
PROJECTIN WE•DLAND ❑ YES
PROJECT M ❑ YDS
IS TW.. OLOG AN ❑ YES
DUILOING: ❑ COMMERCIAL
URBAN INTEPFACE AREA ❑ NO
PLOOD Y.ONR ❑ NO
EICEILER HOME? ❑ NO
DESCRIPTION OF WORK
TOTAL VALUATION:
• 1•, .1• .Ir .;VL•.
By my signature below,( certify to each or the Following: [ am the property o.+mer or authorized agent to act on the property owner's behalf. l hove read this
application end the information I have provided is correct. I have read the Description of work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buil 'ng construction, I authorize representatives of Cupertino Io cuter the above- id'ent`ifiedropertyf or inspection purposes.
Signature ofApplicant/Agenl:
Date: �--1 (`�
SUPPLEMENTAL INFORMATION REQUIRED
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SMOKE I CARBON OXIDE ALARMS
OWNER CERTIFICATE F COMPLIANCE
,030{9 I ENU - CUPE i tt 3 CA 950'14., 255
(408)777-3228 - FAX {408) 777-33,33 A buil 1
PURPOSE
This affida-'rit is a'self-certification for the illsta]],-4tion Of all required Smoke and CarbonNilonoxidie Alarms
for Compliance with 2016 CSC ec ori R314, 21.116:B Sections 120 and 72112 where no lrrter�o# access
for inspections are required.
EVER lel; R ATf "
'Existing single-family and multi -family dwellings shall leo provided with Smoke Alarms and Carbon
Monid alarms. IN"hen the valuation of additions, alterations, or repairs to existing dwelling a gists exceeds .t etzan ar.trJtls nr.?."i 1C,c it flYrklasas azacio, arca
aonoxi e Alarms be installed in ilie following locations -
AREA
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sleeping area in the in-n-nedi at % i irdt_g of
the edTOOMi 5) i
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'Within each Sleepin �
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Carbon Ionoxide alarms axe not required in dwellings which do not contain fuel -burning appliances and that
o rata lea x_(,, arr att£ac}red ar e. Carbon. n-ionox de ala:rre s combined with smoke al„arnis shall cornply with
CBC Section 420.6 and shall be approved by the Office of the tate Fire vfars:hal,
l.> g ° r rzl lt. lr rl� °elli,r} snits a ltl r o Corr r aercial p , et s l p l , rrla,rerr s z t se s: ; l;, l atta r c lreratc-d,
lx, existirt- dwelling units, alarms axe permitted to be so lily, battery operated whererepairs or alterations € o
not result in the .removal of wall and ceiling finishes or 'there is oac;ce s by means of attic, basement or craw]
space - Refer to CRC Section'.R314 and CBC Sections 907.2.11.1t arra 42 .61, An electrical permit is requ ired for
atarrns which mist be connected to the building Wiring.
As owner of the abovt>-re eren ed property, .l herQbe f ceriffy that the alarrn(referenced above has/have has/havebeen
installed in accordance itll the manufacturer's Instru tions and in compliance ivit l the California uil€ in
and California rZesidential. odes. The lars s specified below have been tests: d a.€`i;, arra iJ 7eration,11, as of the
date sizned laelavv.
Address:
-I s` `� s' G arrrlt..: t w (f
ec fy IN"um er ofAlarms- Smoke .Ianns, 4' Carbonlkknioxide 17c.tectors-
1 hmi && read apd'a fee .c com. 3" With. the ten and co,,i'2Fdons of st{ris si'al`v°me t
F^onfractor
Agart's) Larne. . Karat�zod
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Smoke and CO f111dt_do r a *eft 12-1 i. t
Iml
Om,,ncr Name
Address
WATER -CONSERVING PLUMBINGFIXTURES
OWNER CERTIFICATE PL
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
VV ,,,tt}__J�777-3225 * Iu (408) a-7-333 _ a:ic=rte r���a�c� car
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is your real property a registered historical siteLJ ;
yes Civil Code Sections, 1101.1 through 1101.8, do not app' f_ Skip the rest of the fc.,rilr arz si "' l batt€ ll, of fbrnln
Question ` No Go to uesti fir 2
?, Does your real tar€ pen llave a license, dplumb r certifying that, dire to the ageor ccs f gurati€itr or th 1rr ap per eir its
pluir.bing,. rr% ;tion of��:r�,ter-c€ resenting .. lu nbing fix -tures is ol, to i tical.ly firasible>
03 Yes Civil Gude Se€rtiolis l i 01, l tlti;ugh 1101.8 do not a1Z 11f.
0 The licensed plurnber•`s certification has beer, prra.Tideo ttl the Building Divisi€ m
Skip the rest of the form and sign bot€oni of form.
No Go to Question 3.
rs water se€ icy permanently disco nected fbr ;€aur buildz'r
££ des Civil Code Sectlions l 1 r I.l ti rtat l l 10 1. d xw fol-jr a<ssi iz bottom €r rr�.€1eresot
0 €eta to Question 4,
Is �,-r?£ar• r•erri larescr`t1. b�,rift 6 rrd a�Yail�lil:e %4r° u:;e cir €rcci�ta<inia� €?xr car- t3�adre �arua 1, t �:;
:.l No Nkfy real property is built and available for use or €ac a Banc at_qr January 1, 1994.
Civil Lade Sections t lto1,1 tlfrou fr 11(11 do riot apply. Ski tl,e res' of the form and sign bottom n1: foram
X Yes My real rnpert s xtlt aral <z�"� 1cz�7 ��}r iia �r i�� a 'stl :` C�I� <it. f�t� x3 Lit 1,
� ; d 94
Civil ode Sections 11=.11.1 thrOU901101.8 apply. Check -one of the three following statements €rind sign
bottom offrat`rn..
Please check 0 N. of the Following:
s ' property is ahig, ,,'_>7 lrrr i!Y restcreWi it real Pro er°NY. `eSeC Civil Codc Section 1' MIA,
On and after Janwary i 20144 building alterations € r irnprovements shall require all non-compliant plumbing fixtun4
to be, replaced witbw-ater-,conser,,ing plumbing iixturea throughout the 1rtlildintOra, or before January 1 2(117, all non-
compliant phialbing fixtures ;4 f1 be replaced with walger-c=snsenirtg 1llianbing futures (regardless . whether
prc ertyunderg«es ,91teradons €rr i 1 zcr -err zts},
°., M propea tJ-is a rrrif7�z,�r cI; �e sr�'<=Frgf�Ir'cal sro�p rty, See ivH Code Section 01,5.
Or, t'and'Lfte; J ail{'ar 1, 201 , stvcificd buildingalterations ori m1`
p t?vernents Alalf require null- eoalpliant
plrrrtzbin'4 ffxt"ur S to be repIaccd %,ith w aier-„ o isen-iii g pIumbin g 1 ,tu es.
carr of before January 1, 20 , all il€ n-compl am plumbing fixtures Miall be replaced w th wa.ter-
OMIS ripg plumbing fixtures throughout the builLltr: (regardl€: � €? ,vlietlxer properry undergoes alterations or
impro enlents,),
� v lar allot i a c f=rr, e rc,rc€< read lard °z°t See Civil it Cod Section 1101.5.
=n•idI 117rt„l. af:t.4„I' 'Ir",rsiirs'i "4 1..lyl3CitleCf atzr.1di11 3.'sier`cltl£ 2fi ta, ai�i1?t`iit'e.:rt€..it:r ,hall ia;iluzr'e fSer- ti.013I11;.<'LT;C
plumbnng iixtures to be repilac d xith water -conserving lilt nio-inn frit ri ,s,
Oil or before Janu&-ly 1, 7119, all non-corglgbant pluirrrairig shall be, replaced. with ,ۥate r- conseiA,:rg.
plumbing fixtures i12F`t3ilgl"wul the building (regardless o -,vinether Property 'nnd i'go s allegations or improvements).
).
is tile owner or own r s agcnt of this propetycertify under penalty of p rj rry that nozcompliant pluanbing fixtures es will be
r cill<•aced prior to date specified ;3€ ove tVitllh water-collser "ing plu iAt" ing "2F0t:ures in accordance with €. ivil Code Sections 1101 .1
through 1:1.61.8, ihFe current (Dol f nnia 1' unibring Code grad tw"alITt1r7,.ta Green Building Standardst:aca . Irrrcl t aa�.�f t.ai. s
h- alliation iitY` ilei€ t , and that the t�" ier ;rs;.et�1i s pluil i ng rIxtures'comply with 11w rs°C uiret-nen-uas indicated n ttip
iabl (,in the follo inn oat e. a
iner or Owner Agent's Signature:
aid signing th i s Certificate, Please return it to
Dater 51W29Q0L7
Building ivtsl tr in order is final yo-ur yo-ubuilding pennit,
.IP 01201 51dvc rleni,-,ed6 4 -f-