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B-2016-2565 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT PITO:B-2016-2565 10342 TERRY WAY CUP ERTINO,CA 95014-2930(359 17 022) F W H ACQUISITION CO LLC BOTHELL,WA 98011 OWNER'S NAME: TS I SHI KU`N AND YUH CHING TRUSTEE DATE ISSUED:03/22/2016 OWNER'S PHONE:614-592-6253 PHONE NO,(425)636-7078 LICENSED CONTRA TOR'S DECLARATION BUILDING PERMIT INFO: License Class PLUMBII G Lic.#987398 Contractor F W H ACQGlSlTlCN CO LLC Date 10/31/2017 X BLDG ELECT X PLUMB I hereby affirm that I an i licensed under the provisions of Chapter 9(commencing MECH X RESIDENTIAL_COMMERCIAL with Section 7000)of Dh ision 3 of the Business&Professions Code and that my license is in full force and effect. JOB DESCRIPTION: REMOVE/REPLACE 38 GALLON WATER HEATER I hereby affirm Bender penalty of perjury one of the following two declarations: 1. 1 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 o the work for which this permit is issued. 2. i have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 o the Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$1394.00 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 t building construction,and hereby authorize 359 17 022 representatives of this c ty to enter upon the above mentioned property for inspection purposes. ( e)agree to save indemnify and keep harmless the City of Cupertino again t liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED may accrue against saic City in consequence of the granting of this permit. WITHIN 180 DAM'S OF PERMIT ISSUANCE OR Additionally,the applies t understands and will comply with all non-point source regulations pert e Cupertino Municipal Code,Section 9.18. 180 DAIS FROM LAST CALLED INSPECTION. Signature Date Issued by:Patricia Garcia Date:08/22/2016 OWNER-BUILDER DE MARATION I hereby affirm that I arf 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. l;as owner of tie 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 t e 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. 1 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 ol the 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 materials requirements under Chapter 6.95 of the Section 3700 o f the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. 1 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 empl y 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(duality 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 at 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 cons ruction,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 eKpenses which may accrue against said City in Lender's Address consequence of the gra iting of this permit. Additionally,the applicant understands ARCHITECT'S DECLARATION and will comply with all on-point source regulations per the Cupertino Municipal Code,Section 9.18. 1 understand my plans shall be used as public records. Licensed Signature Date Professional V®i �Vi aViv akIj I: rcja r_'db_t_ water heater _ 001/002 COMMUNITY DEVELOPMENT DEPARTMENT, BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 ( C ►PLE `FYNO' {406)777-3228.•FAX(4D6)777-3333•bu' u er t0M-1.S C UMBINQ MECHANICAL !! j y I''% �j� BLBCTNtNGAL MISCELLANEOUS OI PROJECT ADDRESS J C'C `.,_VAPN '01 OtivI�R NAME �`4�1 ( �? �a NQ, &LL; k PHONE �� ,'l rO J✓ E-MAIL STREBT ADD SS CITY.STATE ZIP Ao �, r FAX CONTACT NA 1� Jv PHONE 917EET ADD S CITY,STATE,ZIP FAX ❑OWNER OWNER-BUILDHR C7 OWNIM AOBNT >-CONTRACToR C7 CORMACTOR AOENt ❑ ABCmucr ❑ENcRauR ❑ ODVVLOPER ❑TENANT CONTRACTOR AML n� �Y. LICENSENUMHER(�� LICEN5ET BU3.LICN(1� COMPANY NA , `,(, Ol 2 Q M MAIL4 �r,n�Ap FAX (,�,.,f Z I \+r�.� ��J �G1d�R V BTR!?!:T ADDRD iAA Q CrtY,3T � e,�l WIC I,�0W G ARCHITECTIEN WEEK NAME LICENSE NUMBER BUS,LIC P COMPANY NAM B.MAIL FAX STREET ADDRE9 CITU,STATS,ZIP PHONE FUSE OF FDarDUPCBX LIMULTFPANILY PROJECTINWUMLAND ❑ VEE PRJ=CTIN ❑YES 13 THE BLDG AN ❑v2B BLtMDINO: COMIERCIAL El CI NO FLOOD ZONO EICHMHOM9? ❑NO D65CRIPTION OF VORK TOTAL vALUATTO P By my signature b 3low,(certify to eaelf of the following; I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and tho information I have provided is correct I have rend the Description of Work and verity It]s accurate. I agree to comply with all applicable local ordinances and 91de laws relating to bui di construction, I authorize representatives of Cupertino to enter the above-t Signature ofAppiiantiAgenC dentlfled property for Inspection purposes. �---�~ :Date: SUPPLEMENTAL INFORMATION REQUIRED ill L . /v1EPA,jisc,4pp Z0ji.dac revised 0412//17