B-2017-1182CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-1182
802 CANDLEWOOD DR CUPERTINO, CA 95014-4653 (369 19 033)
HOMEOWNER
BUILDER
OWNER'S NAME: RUDD BARBARA TRUSTEE
DATE ISSUED: 07/21/2017
OWNER'S PHONE: 408-857-1289
PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO -
License Class Lic. #
Contractor HOMEOWNER BUILDER Date
X BLDG —ELECT —PLUMB
MECH X RESIDENTIAL COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
_
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
MASTER BEDROOM AND HALLWAY BATHROOM REMODEL (80
I hereby affirm under penalty of perjury one of the following two declarations:
S.F )
1. I have and will maintain a certificate of consent to self -insure for Worker's
Compensation, as provided forby Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
2. 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
Sq. Ft Floor Area:
Valuation: $20000.00
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
APN Number-
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
369 19 033
and state laws relating to building construction, and hereby authorize
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 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 7/21/2017
Issued by Abby Ayendg
Date: 07/21/2017
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
t. I, 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 for
inspection.
_sale (Sec.7044, Business & Professions Code)
_2. I, as owner of the property am exclusively contracting with licensed
Signature ofApplicant:
to construct the project (Sec.7044, Business & Professions Code),
Date: 7/21/2017
/�i—contractors
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
t. 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 of the work for which this permit is issued.
z. I have and will maintain Worker's Compensation Insurance, as provided for by
HAZARDOUS MATERIALS DISCLOSURE
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
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
permit is issued.
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
material. Additionally, should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If, after making this certificate of
will maintain compliance with the Cupertino Municipal Cod , Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & SafetACode ons2550 255 , and 25534.01Labor
Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
Owner or authorized agenr
APPLICANT CERTIFICATION
Date:/211122 017
LENDING AGENCY
1 certify that I have read this application and state that the above information is
CONSTRUCTION
I hereby affirm that there•is a construction lending agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
of work's for which this permit is issued (Sec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
Lender's Name
to enter upon the above mentioned property for inspection purposes. (We) agree
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Address
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands
ARCHITECT'S DECLARATION
and will comply with all non -point sourzp regulations per the Cupertino Municipal
I understand my plans shall be used as public records.
Code, Section 9.18.
Signatur ` ��fi Date 7121/2017
,Professional
Licensed
CUPERT11140
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildingCo)cupertino.org
U NEW CONSTRUCTION ❑ ADDITION 54 ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESS 0 ( APN # C�j 9
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9
ObVNER. NAMEL,-r,- Y_0,
0, ay a( PHONE ^ E-MAIL
STREET ADDRESS- � � � � � ®� CITY, - STATE, ZIP Pa � ;r^ � FAX
F
NAME PHONE E-MAILAl li P' iof DDRESS CITY, STATE, ZIP FAX
❑ OWNER WOWNER-BUILDER E3 OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE NUMBER
LICENSE TYPE
BUS. LIC #
COMPANYNAME
E-MAIL
FAX
STREET ADDRESS
__7ARCHITECT/ENGINEER
CITY, STATE, ZIP
PHONE
NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS b 4
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK4in6�m
C121 el , '�, k - ('
y - r .. CLA/ tel
PLANTIINGAPPL# []NO PLANNING APPROVAL LETTER
EXISTING USE I
PROPOSED USE
CONSTR. TYPE
# STORIES_
USE
TYPE
OCC.
SQ.FT.
VALUATION ($)
EXISTG
AREA
NEW FLOOR
AREA
DEMO
AREA -
TOTAL
NET AREA
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act In the pro erty owner's behalf. I have read this
application and the information I have provided is correct. I have read the Des ion of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buil 4cons ction. I aLltlpyize r tiv Cupertino to enter the above -identified property for inspection purposes.
Signature of ApplicantlAgent: Date: 7 `? 114
SUPPLEMENTAL,, INFORMATION REQUIRED
>at-,yw
BATHROOM `i�dllde
REMODEL AREA
KITCHEN
REMODEL, AREA
_
OTHER
REMODEL AREA
,
— New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
ATTACH
k DWELLING UNITS:
IS A SECOND UNIT ❑ YES
SECOND STORY ❑YES
BEING ADDED? [:]NO
ADDITION? ❑NO
PRE -APPLICATION []YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑YES
jtECE
TOTAL VA@LyUATION:
PLANTIINGAPPL# []NO PLANNING APPROVAL LETTER
EICHLER HOME? ❑NO-'"
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act In the pro erty owner's behalf. I have read this
application and the information I have provided is correct. I have read the Des ion of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buil 4cons ction. I aLltlpyize r tiv Cupertino to enter the above -identified property for inspection purposes.
Signature of ApplicantlAgent: Date: 7 `? 114
SUPPLEMENTAL,, INFORMATION REQUIRED
�
❑OVER TAE COUNTER
❑ BUM; GPLANREiiER'
— New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
❑ >rXPRcss
�"
❑ Pi AlvNrrrG Pi AtvRE�lw
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
STANDARD
❑ rlJsi>c�YORxs
_
if any Hazardous Materials are being used as part of this project..
form❑
❑
❑
LAIIGE , ��3
fi1RE DEPT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
❑ MAJOR❑AIRvEYU>
R DrsrRrcT
submittal of'Building Permit application.
BldgApp_201 Ldoc revised 06'21/11
We are providing you with an`Owner-Builder Acknowledgmentand-Information Verification form to make you'aware of
your responsibilities and possible risk you may incur by having this permit issued in your name a5 the Owner -Builder, ;We
will not issue a building permit until you have. read, initialed your understanding of each`provision signed, and
returned this form to us at our officiaUaddress indicated: An agent of the owner'cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority. _
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS. Please read and initial each statement below to signify you understand or verify this information.)
f,I understand a,frequent practice of unlicensed persons is to have -the property owner obtain an -"Owner=
ilder"building permit, that erroneously implies that the property,owner is providing hisor her own labor -arid material
personally. I, as an Owner -Builder; may be held liable and subject to serious financial risk"for any injuries sustained by
an unlicensed person and his or her amployees`while working on my property. My homeowner's.insurance;may not,
provide coverage for those injuries-. I -am willfully acting as an Owner -Builder and am aware of the limits of my
insurance coverage for injuries to workers on my. property.
*1 understand building permits are not required to be signed by property owners unless they are responsible for
hewnstructibri,and are not hiring a licensed C.ontractor,to assume this responsibility: .,
I understand as an "Owner -Builder" I am the responsible party of record on the permit. 1 understand that i may
bo-itel myself from .potential financialrisk by hiring a licensed Contractor and having theTiarmit, filed in his or -her
name instead of my own.
r
1 understand Contractors are required by law to be licensed and bonded'in California and to list their license
numbers on permits and contracts: y
I understand if I- employ or otherwise engage any persons, 'other than California licensed Contractors; and the '
otalue of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered an "employer" under state and federal law.
1 understand if I' am considered an "employer" -under state and federal law, [must register with the state and'
doral government, withhold payroll taxes, provide workers' compensation disability insurance,, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
I understand under' California Contractors' °State License Law, an Owner -Builder who builds single-family
residential structures cannot legally baifd them with th ' -i ' '- nt to offerthem for sale, `unless all work i"s performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is performed under"contract with a licensed general building Contractor.,
08. 1 understand as an Owner -Builder if 1 sell the property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
defects in the workmanship or materials.
OwnerBuilderForm 2010.doc revised 04/14/10
9. I understand I may obtain more information regarding my obligations as an "employer" from the Intern
Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments-,
and the California Division of industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed
contractors.
. I am aware of and consent to an Owner -Builder building permit applied for in my name and under -stand that I
am the party legally and financially responsible for proposed construction activity at the site address listed above.
61. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
yal, applicable laws and requirements that govern Owner -Builders as well as employers.
12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
you contract with someone who does not have a license, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property, you may be held liable for damages. If
you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS: Please complete the following construction lending agency information)
I hereby affirm that t ere ' construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Address:
Before a building permit can be issued, this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note: A copy of the property owners drivers license,
form notarization, or other verifcationn cceptable to the cityyay be required to be presented when the permit is issued
to verifv the vronerty nwner'c cin A
I Property Owner's Signature:,/�1, . 17 , Date: 9111V / / % 1
---- -- - ---- -------------------------=---------—
--------------------------------------------------------------------------------- -_
(NOTE. The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner -Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, t hereby
authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an
Owner -Builder Permit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address:
Name of Authorized Agent:' Tel No
Address of Authorized Agent:
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: Date:
'° OwnerBuilderForin 2010. doc revised 04/14/10
Abby Ayende
07/24/17
07/24/17
B-2017-1182
Abby Ayende
Abby Ayende
07/24/17