12080206 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: 839CANDLEWOOD DR CONTRAC'MR:DAVID&MADELINE PERMITNO: 12080206
ROTOLO
OWNER'S NAME: DAVID&MADELINE ROTOLO 839 CANDLEWOOD DR DA'Z'E ISSUED:08202012
OWNER'SI'BONE: 4083669746 CUPERTINO•CA 95014 PHONENO:
❑ LICENSED CO\INAC1'OR'S DECLARATION BUILDING PERMIT INFO: BLDG 1- ELECT F- PLUMB F-
License Class Lie.#
plECll r RESIDENTIAL . COMAIERCI,\L
Contractor Date
hereby affirm that I out licensed under the provisions of Chapter 9 JOB DESCRIPTION: INSTALL ELECTRICAL IN 10 X 12 SHED
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the 0mllowing two declarations:
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
perl'orntance of the work for which this pemtit is issued. Sq.Ft Floor Area: Valuation:5450
I have mid will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the perfomrmice of the work for which this
permit is issued. APS Number:36918025.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct, lagrce to comply with all city and county ordinances amJ state laws rel"ting PERA'iIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WiTHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of die tl
granting of this permit. Additionally,the applicant understands and will comply T 1
with all non-point source regulations per the Cupertino Municipal Code,Sectiam Issued by: Date:VV �(VU 1l/VI
9.18.
Signature Date
RE ROOFS:
❑ O\VNER-BUILDER DECLARATION All roofsshall be inspected priortommy roo0ngiraterial beiiginsCalled.I(aroofis
installed withma first obtaining an inspection,I agree to remove all new materials for
hereby affirm that I am exempt from the Contractor's License law for one of inspection.
the following svo reasons:
I,as owner of the property,or my enmployces with wages as their sole compensation, Signature of Applicant: Date:
will do the work,mid the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,us owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Prot'essions Code).
1 hereby amrnm under penalty of perjury one of the following three IL\'/.ARDOUS JIATERI.\1 S DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California l lealth&Safety Code.Sections 25505,25533,and 25534. I will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino\lunieipal Code,Chapter 9.12 and.the Health&
performance of the work for which this permit is issued. Safety Code.Section 25532(a)should 1.store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should 1 use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District 1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
p I Iealth&Safety Code,Sections 25505.25533.and 25534.
1 certify that in the performance of the work for which this permit is issued,I shall
not employ any person in any manner so as to become subject to the Worker's Owner r>�uthnrizrJ a�gen=_
Compensation laws of California. If,alter making this ceniftcate of exemption,I Z
become subject to the Worker's Conipensmion provisions ofthe Labor Code,I must
forthwith comply with such provisions or this permit shall he decried revoked. CONSTRUCTION LENDING AGENCV
1 hereby affirm that there is a construction lending agency for the performance of mwrk's
\I'I'LIC.\N'I'Ch R'I'IPICA'I'ION for mehich this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
correct.I agree to comply with allcity anal county ordinances grid state laws relating
to building construction,and hereby authorize representatives of this city to enter Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to stave
indenmily and keep harmless the City of Cupertino against liabilities judgments, AKCII I'I'FCI"S DECLARATIONcosts,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupenino Municipal Code,Section
9.18. Licensed Professional
Signature Datc gal //
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 839 Candlewood Dr. DATE: 08/20/2012 REVIEWED BY: jsg
APN: BP#: 'VALUATION: $450
•PERMITTYPE: Electrical Permit PLAN CIIECK TYPE: Alteration /Addition / Repair
PRIMARY SFDDlPENTAMATION
USE: or PERMITTYPE: 1REAP10
WORT: Install electrical in 10 x 12 shed
SCOPE
APPLIANCE/EQUIP TYPE FEF, ID QTY UNITS BP FEES
Recep/Switch/Outlets 1BREMRECEP 1 # $45
TOTALS: $45.00
Medi. Plan Check Phuub. Plan Cheek Elec. Plan Check 1 0.0 1 hrs $0.00
blecb. Permit Fee: Plumb. Permit Pee: I Elec. Permit Fee: IEPERAIIT
Other,llerh.Insp. Other Plumb Insp. Ll I Other Elec. Insp. 0.0 hrs $45.00
Jlech. hvp. Fee.: Plumb. losp. Pee: Eler.Insp.Fee:
NOTE: This winmte does not include jets due to other Departments(i.e. Planning, Public Works, Fire,SanitarySuver District,School
District, etc.). Thesefees are baser/nn the prelindnart information available and are onln an estimate. Contact the Dept for atldn'I info.
FEE ITEMS (Fee Resolution I1-053 E0: 7/111/) FEE QTY/FEE mi SC ITEMS
Plan Check Fee:
Suppl. PC Fee
PME Plan Check: $0.00
Permit Fee:
Stipp/. hap Fee
PME Unit Fee: $45.00
PME Permit Fee: $45.00
Consn•tiction Tax:
Administrative Fee: IAD,tihv $42.00
Work Without Permit? O Yes Q No $0.00
Advanced Planning Fees:
Travel Documentation Fec: IT&tVDOC $45.00
Strong Motion Fee: IRSEISAIICR $0.50 Select an Administrative Item
131dg Sids Commission Fcc: IRCESC $1.001 1
SUBTOTALS: $178.501 $0.00 TOTAL FEE: $178.50
Revised: 0 7/0112 01 2
I Zoe v �
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228• FAX(408)777-3333• building(5cuoertino.org misc
[_]PLUMBING ❑MECPIANICAL ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS H,r O ao ,J(� APM1 n 7/'_ C? Q— / _ O�l�
lyntf
OWNER NAME PHON L� E-MAo1L C
STRCE7 AD RESSiv/I CITSTATE,ZIP I FAX CA n r P v C /
CONTACP NAM PHONEIL
G E- TAs 44C rt7u, e'n
SEREk A RFS$ OD I rY. TATE, ZIP - FAS
I(DWNER ❑ OWNER BUILDER ❑ OWNER AGEM17 ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCH= ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAME LICENSE NUMBER I.JCENSETTE BUS.LICa
COMPANY NAME E-MAIL FAX
STREET ADDRESS CIT',STATE,ZIP PHONE
ARCHIfECT/ENGINEER NAME LICENSE NUMBER BUS.LIC s
COMPANY NAME E-MAIL FAR
STREET ADDRESS CITY.SPATE ZIP PHONE
USE OP ❑SFDnr DUPLEX ❑ MULTI-FAMILY PROJECT IN WTLDLAND ❑ YES PROJECT IN ❑�1�YES IS THE BLDG AN ❑ YES
BUILDING: �CONMERCIAL URBANINTERFACEAREA NO FLOOD ZONE 'l�NO EICHLE HONE' 10 NO
DESCRIPTION OF WORK
e e
TOTAL VALUATION: (r S� A UO RECEIVED BY:
By my signature below,I certify to each of the following: I am the propeny owner or authorized agent to act on the property owners behalf. I have mad this
application and the information 1 have provided is correct. I have rear)the Description ofWork and verify it is accurate. I agree to comply with all applicable local
ordinances and State laws relating to building construction. I authorize representatives ofCupenino to enterThe above-identified roperty for inspection purposes.
Signature of ApplicanOAgent: i _ ,�� —,® Date:
SUP LEMENTAL INFORMATION REQUIRED OFFICE ush ONLY
❑ OVER-l'IU:COUS-I ER
❑ EXPRESS
1
❑ STANDARD
i
❑ LAROE
❑ .MAJOR
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