B-2018-0914 CITY OF CUPERTINO BUILDING PERMIT
BU ILDINCADDRESS: CONTRACTOR: PERMITNO:B-2018-0914
22824 LONGDOWN RD CUPERTINO,CA 95014-2650(342 33 006) P W H ACQUISITION
CO LLC
BOTHELL,WA 98011
OWNER'S NAME: DATE ISSUED:05/29/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class CC=36 Llc.4987398
Contractor F W H ACQUISITION CO LLC Dale 10/31/2019 X BLDG_ELECT X PLUMB
I herebyaft'i that 1 am licensed under the provisions of Chapter 9 _MECH eX RESIDENTIAL_COMMERCIAL
� p p (commencing
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
(N)50 GAL WATER HEATER-GARAGE
I hereby affirm under penalty of perjury one of the following two declarations:
r. I have and will maintain a certificate of consent to self-insure For Worker's
vlft Compensmimy as provided for by Section 3700 of the Labor Code,far the
,`-y ►1 performance of the work for which this permit is issued.
�-s I have and will maintain Worker's Cmnpeasatiou Insurance,as provided for by
Section 3700 or the Labor Code,Por the performance of the work for which this
permit is issued. Sq.Ft Fla.,-Area: Valuation:$1534.40
APPLICANT CERTIFICATION
'I certify that I have read this application and slate that the above
information Is correct.I agree to comply with all city and county ordinances APN Number: Occupancy Type:
and slate laws relating to building construction,and hereby authorize 34233 006
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 9.1 B. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 05/29/2018 Issued by:Jasmine Archbold
Date:05/29/2018
OWNER-BUILDER DECLARATION
I hereby.o irm that I um exempt from the Contractor's License Lary for one at the RE-ROOFS:
following tyo reasons: All roofs shall be inspected prim to any fooling material being installed If e roof is
m. 1,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 far inspection.
sale(Sec.7044,Business&Professions Code)
z. I,as owner of the property,am exclusively contracting with licensed Signature ofAirpliaout:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:05/29/2018
1 hereby am-in under penalty a]perjury one at the yellowing three declarations: ALL ROOF COVERINGS TO 13E CLASS"A"OR BETTER
r. 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 ofthe work for which this permit is issued, HAZARDOUS MATERIALS DISCLOSURE
2. 1 have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous nmteri Is requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the perfarmaoce of the work for which thisCali1'ornfa Health&Safety Code,Sections 25505,25533,and 25534.1 will
at permit is issued. afntain compliance with the Cupmrdno Municipal Code,Chapter 9.12 and the
3. 1 certify that in the performance ofthe work for which this permit is issued,I Health&Safely Code,Section 25532(a)should I stare or handle hazardous
station employ any person in any moaner so as to become subject to the mmerinl,Additionally,should 1 use equipment or devices which emit hazardous
nntaminants as defined by the Bay Area At,Quality Management District 1
Worker's Compensation laws of California.If,atter making this certificate of sy111 maintain compliance with the Cupertine Municipal Code,Chapter 9.12 and
exemption,l become mbject to the Worker's Compensation provisions of the the Health&Sn1'ety Code,Sections 25505,25533,and 25534.
Labor Code,l must forthwith comply with such provisions or this permit shall
be deemed evoked, Owner or authorized agent:
APPLICANT CERTIFICATION Date:05/29/2018
I certify that I have read this application and state that the above information is CONSTRUC'T'ION 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.
SignatureLicensed
Date 05129/2018
Professional