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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
850 CANDLEWOOD DR CANDLE
UW CONSTRUCTIQN
OWNER'S NAME:
PERMIT ISSUE DATE
PHO
CONTROL NO.
(408) 687-8282
ARCH11ECTIENGiNEER:
BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
m full force and effect
REVISION: ADD FOOTING TO BEDROOM
Date ense C"' Contkractor
ORIGINAL# 08070091
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I sm exempt from the Conraciors 1Jccnse Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct. alter, improve, demolish, or repair any structure
'
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
$1000
APN Number
Occupancy
ane
P Y Type
Section 70313 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
3691 9028.00
❑ L as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work and the structure Is not intended or offered for sale (Sec. 7044, Business
and Professions Cod= The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himsecif er through his
own employers, provided that such improvemdmLs are not Intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Conracwrs Li-
cense Law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a conuaaor(s) licensed pursuant to the Conu%Lwrs
License Law.
❑ I am exempt unjder S B & P C for this reason
Owner I� I'`'J Y Date�V
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of pe jury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -Insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued
❑ I have andtwill maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is Issued
'
My Workers Compensation Insurance artier and Policy number are:
Carrier Policy No.:
CERTIFICATE OP E EMFITON FROM WORKERS'
COMPENSATION INSURANCE
(-his section need not be completed if der permit is for one hundred dollars ($100)
or Ices.)
1 certify that in the performance of the work for which this permit Is issued 1 shall not
employ any person in any manner so as to become subject to the Workers Compensation
Laws of California. Dat
Applicant
NOTICE TO APPLICA . If, ifter making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this pernit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit Is issued (Ser 3097, Clv. C-)
Lenders Name
Lenders Address
1 certify that I have read this application and sum that the above information is
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comet. l agree to comply with all city and county ordinances and state laws rcladng to
building construction, and hereby authorim 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
liabilitira, judgments, costs and expeases which may In any way accrue against said City
in consequence of the granting of this permit
r
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE yLATIgNS.
S.
Re -roofs
Type of Roof
Q WO q
Signature ofAppli ntractor I Date—
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hrmdous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code. settlz553z(a)7
All roofs shall be inspected prior to any roofing material being installed.
Yes
❑Yes ❑No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
Diurict7
❑ Yes ❑ No
1 have read the hazardous materials requirements undcrChapier 6.95 of the Califor-
nia Health & Safety Codc, Sections 25505, 25533 and 25534.1 understand that if the building
does not currently have a tenant that It Is my responsibility to notify the occupant of the
requirements hleh est be met prior to issuance of a Cen;ncaue of Occupancy.
Signature of Applicant Date
I1 � I
Al l roof coverings to be Class W" or better
—
s
Owner or sod `