B-2017-1621 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1621
20176 HOGUE CT CUPERTINO,CA 95014-2342(316 24 041) F.W H ACQUISITION
CO LLC
BOTHELL,WA 98011
OWNER'S NAME: MURPHY JOHN P AND SANDRA S TRUSTEE DATE ISSUED:09/20/2017
OWNER'S PHONE:408-394-5853 PHONE NO:(425)636-7078
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-36 Lic.#987398
Contractor F W H ACQUISITION CO LLC Date 10/31/2017 X BLDG _ELECT X 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:
REPLACE WATER HEATER SAME LOCATION
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
4 performance of the work for which this permit is issued.
2. 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 Area: Valuation:$1511.14
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 316 24 041
representatives of this city to enter upon the above mentioned property for
inspection;purpbses. (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. NO n 180 DAYS FROM LAST CALLED INSPECTION.
` r _ r 11-P/
ignature V Date Issued by:Phuong Devries
Date:09/20/2017
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 io construct the project(Sec.7044,Business&Professions Code). Date:
I hereby affirm underlpenalty;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,mainthin Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 370+0 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
a. I certify ihat`in theperformance 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 Compensatioi 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 mustforthwith comply with such provisions or this permit shall `�
l deemed revoked. ' Own or authorized agent: F 1-it
•APPLICANT CERTIFICATION Datgl
I certify thatl have read this application and state that the above information is a - R _ I i L kD x k Y
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 coristruction,'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
consequeride.of the granting of this permit. Additionally,the applicant understands
and will coniply!wlth aiI'non'point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. 'i ' ' I understand my plans shall be used as public records.
Licensed
Signature Date Professional
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103152
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GENERAL PERMIT APPLICATION
COM MIAITYDEVELOPt4ENT DEPARTMENT-BU1LDING.DMSiON• .. . . -
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10300 TORRE AVENUE•CUPERTINO,('A 95014-3255
(408)777-3228•FAX{408)777-3333•bLIMinCIOLCuponino.ote) ' '-' ., •
CUPERTINO
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. PR1)-*'fF A ImMt"S 20176 HOGUE COURT t Apu0
0I'Vi1 NAME MURPHY.JOHN ' ; PH91q 4083945853
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.::1 RAPT ADDRUS 20176:HOGUE',COURT CIIY,SIAIL2IP CUPERTINO CA •95014 - P.;;'; "—:—
CaNtACT N.,..ME Katy Kehle' . .FAST Water Heater mm'E 425-636-7084 t-mAILIO(eti 00}10Naterh'eatencorn
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i) '5 11715 N Creek Pkwy S., C-106 (1'. "'"'.'m Bothell WA 98011 l' 425-636-7084
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4,- 101A2..N'Al0A-IION $1,511,14 _ , ;(1CLIVED BY: /
Cy my signature ttlow..1 centfy to each ofthe cnilowingi I ani the proptqw owner or authorized agent lo act ontheID tgyi.;tncr's bchall"..1 have road this
ariptir..ation and the informatkm I bavc,prokiido.tis coma I liat'emaci the,15.25.e.i:iptirin of Wolk and N'erify iris aectuate, E apex to coroplv is LII all applieab1e local
otdinlinees awl mate Smc retateng to riitylit Inv:mirth a. I aTh;riroroaritatircis of CuriCrn Pe.>1 o inter the abfo -itientitislpoweety l'o7 in pc immises.
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Signature of Applicatat'Agent . /,_.,. , A: .), . Date. 9/19/2017,
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SI il3PLEM ENT AI.INFORMATION REQUIRED ,_ „ _
OFTICE USE°NIA
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