04030259 CITY OF CDPERTINO �, '0 ET
.�
BUILDING DIVISION PERMIT _
BmI.DING ADDRESS: _ RUDOLPH & SLETTEN INC PERMIT ND04030259
OWNER'S NAME: PERMIT IS6U0 DATE
NE:H SANITARYO. 0 OL NO,
ARCHITECfIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�tOG- LICENSED CONTRACTOR'S DECLARATION Job Description
1 Mmhy affirm Nat 1 am licomed amrrttss�1199fff pmviaiom of Cheplr 9(cemmendng- P
wire Section 7IXXp of iviaion Sof NC Huu'lay({erb Profesaionn Codc.and my license is ��
•mum Band ✓ (p REVISION~�IN HOUSE USE ONLY
01 Lice Isar Lie.N R2
na. Date nct `'NO--NEW_-.P.E MIT ISSUED/ ORIG. #03090179
a� AR HITF.CI'S DECl/ ATION
ay7 I un d my plena shell he uxdiilsGhgc records
�a
Licum ad Prolmed.ruil
OWNER-BUILDER DECLARATION
1 hereby.IBrm that 1 am cacmpt from the Cantncmes License Law for the
i
p O following mason.(Secdon 7031.5,Business and Pmfessimsa Code:Any city or county
x S which requires a permit m cnmlrvel,¢Iter,improv4.demnlixh,or repair any structure
ea'^ prior m its issuance,also requires the applicant for such Permit m file a signed statement
p=p�o Valuation $0
p�3 (m..memg with Section 7")of Division 3o(IW Buainessand PmIcaci...Code)ur
tha
.. t he is exempt Nemfmm and Ne bass for rite alleged exemption.Any violation of
that he is licensed pursuant to the provision ofthe Contractor's U...Law(Chapter 9 Sq.Ft. Floor Area
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not moon Nen five hundred dollen($500).
❑I,"owner of the Property,Or my employees with wages u their sol compenalion, 31607045 . 00
will do the work,end ma.meoun is rommeMad or offered forrae(See 7044.Business Required Inspections
and Pnfesalons Code:The Conttamor'a License Law does mot apply m e ns an owner of q P
prepeny who build•c r improves thereon,and who does such work himself or through his
ewnemployces.provided that such improvement an notintended oroReond forage.IL
however.the building or improvement is sold within out year of completion.Ne owner.
builder will have the burden of preying that M did not build or improve for purpose of /}.�
.a.). V !
❑I,as owner of me property,am exclusively contracting with licensed contractors;In v
construct me project(Sec.7044.Business and prefasaons Code:)The Contractor's Li. \ F
came law does not apply to an Owner of property who builds or improv theater,and.
who contracts for such projects with a convazmKs)licensed pursuantw the Ca bolo or's v
License Law.
❑I am exempt under Sec .B&PC fm this resson
OwnerDate
WORKER'S COMPENSATION DECLARATION
1 hereby aiBrm under penalty of perjury one of the fallowing declaromang -
1 have and will maintain a Certlficate of Consent to self-inum for Woftes Compton-
nation,as provided for by Section 3700 of the Isbor,Coda,for the Performance of me
work for which this permit is issued.
❑1 have and will maintain Worker's Compeesation Insurance,m required by Section
37 of the labor Cock,for to performance of me work forwhich this permit is issued.
ork es Compensation Iwwnce canter and Policy number ma: s
artier.QA-fMfllpl ejtCNATL-',C Policy No.:w,_ 49 3
CIO CERTIFICATE OF EXEMPTION FROM WORKERS'
Li COMPENSATION INSURANCE Io//
(This rection need netbecompleld if tie permit Is fmonehundred dollars($100)
or less.)
1 cerdfy that in the performance of me work for which this permit is issued,I mall not
employ any person in any manner so ss to become subject to the WorkoW Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Ccniftcaa or Exemption,you mould
become subject m the Worker's Compensation provisions of the Labor Code,you must
wJ z forthwith comply with such provisions Or this permit&hall x deemed mvokcd.
z O CONSTRUCTION LENDING AGENCY
t~ 1 hereby affirm that then is a construction lending agency for the Performance of
Ix r7 the work for which this permit it issued(Sec.3097,Civ.C.)
ALender's Name w
r7z Lender's Address
U Q 1 certify that I have read this application and sate that the above Information it
V. F correct.I agree to comply with all city and county ordinances magma laws relating to
C building construction,and bemby authosim mpresenativ of this city to enter upon me
.hove-mentioned prepeny for inspection purposes. , q
We)•gone to save,indemnify and keep harmless the City of Cupertino against
tF—t IG liabilities,judgment,cast cad expenv which may in any way acme against sad City
6)7 in consequence of me granting of this permit /
'7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON- DINT Issued by: Date
SOU LATIONs. nn��
Re-roofs
I ammo(ApplicanUContracmr Dal
HAZARDOUS MATERIA LOSURE Type of Roof
Will tis applicant or futrne building Occupant store or handle haamdous material
as defined by the Cupenino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Section 15531(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑res ¢
Will the applicant Or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit nOardnm air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Ycsve o
I haread the havandous materials requimmena underchapter 6.95 of the Calif.,.
ria Hcalth&Safety Code,Scctiom 15505,25533 and 25534.1 mucragned that ifine Wilding
dues not currently have a tenant,mat it is my responamility to nodfy tie Occup t of Inc
onyvirem i<nmontbemmpdormi Cedric r y�anC Signature of Applicant Date
�44caner or authari7ed agcm C.Y ate All roof coverings to be Class"Brr or better