B-2018-0808 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0808
19627 AMHERST DR CUPERTINO,CA 95014-2407(316 29 089) F W H ACQUISITION
CO LLC
BOTHELL,WA 98011
OWNER'S NAME: DATE ISSUED:05/10/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C36 Lic.#987398
Contractor F W H ACQUISITION CO LLC Date 10/31/2019 X BLDG_ELECT X PLUMB
1 hereby al'Brm that 1 am licensed tinder the provisions of Chapter 9(rommendng 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:
REPLACE 50 GAL WATER HEATER(SAME LOCATION)
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
, Compeusation,as provided for by Section 3700 of the Labor Cade,for flee
performance of the work for which this permit is issued.
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 Flom•Area: Valuatlem$1645.69
APPLICANT CF.RTiFiCA'fION
I certify that I have read this application and state that the above
information is correct.I agree to comply with a1I city and county ordinances APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 31629099
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 ORAdditionally,the applicant understands and will comply with all non-point
source regulations per the Cupertino unicipal Code,Section 9,18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 05-10-2018 Issued by:Kim Dunbar
Date:05/10/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt train Ilse Contractor's License Law for one of the RE.ROOFS•
following two reasons: All roofs shall be inspected prior to any rooting material being installed.It's roof is
t. L as owner of the property,or ury employees with wages as their sole installed without fust obtaining an inspection,I agree to remove all new materials For
compensation,will do the work,and the structure is not intended ar offered For inspection,
sale(See.7044,Business&Professions Code)
z f,as owner of tbu property,am exclusively contracting with licensed Signature ol'Applieant:
contractors to construcl the project(See.7044,Business&Professions Cade). Date:OS-10-2018
I hereby affirm native penalty of perjury one ot'the t'ollowing three declarations: ALL 1200E COVERINGS TO BE CLASS"A"OR BETTER
t. 1 have and will maintains Certificate of Consent to self-Insure£or Worker's
Compensation,ex provided for by Section 3700 of the Labor Code,for the
performance ofthe work far 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 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 issmd. maintain contplimue with the Cupertino Municipal Code,Chapter 9.12 antl the
s. 1 certify that in the performance of the work for which this permit is issued,I Health&Safer),Code,Section 25532(:)should I store or handle hazardous
shall not employ an person in any to become subject to the material.Additionally,Should 1 use equipment or devices which emit hazardous
p y• y p y mannm so as j •contaminants as defined by the Bay Area Air Quality Management District 1
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, and 25534.
Labor Code,l must forthwith comply with such provisions or this permit shall
be deemed invoked Owner or authorized agent:
APPLICANT CERTIFICATION Date:05-10-2018
1 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.
SignatureLicensed
Date 05-10-2018
Professional