03050136 CITY OF CUPERTINO =*" �a,»��"6'a• � + z '`£' M
BUILDING DIVISION PERMIT ,COLVTRACTOYt,TNFOt2MATIO .-;
BUILDING ADDRESS: RUDOLPH & SLETTEN INC PERMITNO03050136
ER's NAME: 989 E HILLSDALE BLV ; . PERMIT @SIIVOATHs
BO8/2003
WLETT P / �
PHONE: (415) 572-1919 SANITARY NO. CONTROL NO.
ARCH ITICT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
300 LICENSED CONTRACTOR'S DECLARATION O O O O
I hereby&farm Met'1 son BacluW under pm.'aia"or Chapter 9(commencing Job Description
with Section 70110)of Division S of Ne IS and Prolosed o ,andmylicenscis
DIRE
I m1�oC an its ctC TI-NEW TRANSFORMER RELOCATIO11--ONIALE93
L Date -' 0Y Convector c
I understand my pl...halllbbeused u public rands JUL 0 2 2003
gs
SPd
Licensed Professional
OWNEm BUILDER DECLARATION BUILDING
<I I Wroso .(Sinn that 11. eampt from tiro Canine Co License law for the BUILDING
00 following meson.(Section 71U L5,Businer.ma Professions Code:Any city"county
$f<i which roquires issuance,permit w cniwnct.alter Wpm w,deermitt ri e sigany tenement
Met hoor tot uensedpursuant
to ws tM anionsofant farduc sucCahnutme'wNe a,Law(ned stawmco
< thatbeiscccuodpunuamwthe pmvivisioofIW eSmicor'aodPmrlaw(Chapter9 Sq.Ft. Floor Area $24 jyl®tion
E (cat he is
(commencing Section can d)M Division r of Ne B ed axe and on.Any
Cade)or
3 g
that he b exempt ihen(rom and Ne bub for Ne alleged exemption.Any vlalailon of
Section 7031.5 by any applicant for a permit subjects,Ne applicml to a drill penalty of �l er 0 0 Occupancy e
not more Nan five hundred dollan(g500). 3 P Y1YP
❑I.u owner of the property,or my employees with wages as their sole c oopcosadon,
will do the work and thestructure b not intended w offered for ale(sec.7044,Budnea —
and Portal."Code:The Contneeefs License Law don not apply m u owner or 102 — PIERS
1 d Inspections
propenywho builds orimprams Ihemon,and whod(sessuch workhimalrorthreugh his
ownemployces,proWded thm&uch imposemenu arenm Intended aaffend f"sale.If. 103 — UFER
hmxewr.we building or impomment is mid within one year of compleunn,Ne owner-
builder wR!hem the burden of proving that he did not Wild or Improve for Improve of 104 - REBAR
ink.). 105 - ANCHOR BOLTS
❑I,u Owner of de proper,,am inclusively contracting with llansed anmacwrs w
co106 - SEWER & WATER
"trYct the project(Sec.7044.Business and Pofrsslans Code)The Com rsous a Li
came Law does not apply to an Owner of property who Wilds or Improv"thereon,cod. 202 — UNDERFLOOR PLUMBING
who contracts for such prejecs,with a conuactor(s)licensed punuant to We ContractoYa
Lime Law. 203 - UNDERFLOOR MECHANICAL
c
❑Iannemptuntler Sec ,B&PC!"Nbrea.n 204 - UNDERFLOOR FRAME
Per Date 205 - UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury as of the following declarations: 301 — ROUGH PLUMBING
❑I ham and will maintain aCWIficanofConunuo a161nsure far Worker's Camper, 302 — TUB fw OR SHOWER
Wion,as pmvidcd for by Section 3700 of the ober Code,f"the performaiwe of Ne 303 - ROUGH MECHANICAL
work for which this permit is issued. 304 - ROUGH ELECTRICAL
❑I ham and will maintain WmkeYs Compensation 1"unnce,as required by Section 305 — FRAME
37000(Nc labor Cod.,for iW perf.Wmce.flW forwhich this permit is issued.
MyW kte,Cnmptnsadon Wurartce e. P icy number am: 306 — HOLDOWNS
Jar-tru.icnni Poll WC 34453aIp3 307 - INSULATION
((M1A/aN////T,���yy-ttf4F7�OMPENSA O�NgURANCEFROM ORKERS' 308 — SHEETROCK
Lf fDtisrltihiTrYad not he completed lfMe,permit is force,hundred dollan($100) 309 - EXTERIOR LATH
cera'')
1310 - INTERIOR LATH
e unity that est dw performancers the work for which t thisPermitrl loved,I mall not 311 - SCRATCH COAT
employ any person In any mannermuwbecome mbjuu.the warhen'Coope"&tion .
Lawacf California.Date 313 - ROOF NAIL
Applicant
NOTICE TO APPLICANT:If.atter making this Certificate of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
become subject to Ne Worker's Compensation previsions of the Labor Code,you must
.J'z f.rmwim comply with such provisions or this permit het be darned rewired. 502 - FINAL PLUMBING ENERGY
z 503 - FINAL MECHANICAL ENERGY
CONSTRUCTION LENDING AGENCY
F� work for
which th that Nen is a coiumeaminn lending agency lot f perrmmmce of 504 - FINAL BUILDING ENER
a> NcwvrkfarwhichNbPermit isissued(Sec.3097.CIv.C.) 505 - FINAL ELECTRICA
IIndee,Name L
W Q
5z LentilAddma 506 - GAS TEST
U O 1 unify that 1 haw rhe this application and show Nat the atom information is 507 - FINAL PLUMBING
{T. F correct.I agree to comply with all city and county ordinanc"and&into laws mlating to
Wilding FINAL MECHANICAL
OU
W ahow-mentioned
ree to
fm inspection
mnify angorpoet %54
FI
G (We)agree to am,indemnify and keep harmless the City of Cupertino against
y Iiabiilties.judgmens,.costs and expenses which may in my way game against aid City TMIL NGin
of g
Ong of
sanceUN R °ANDS AiND WILL COMPLY WITH ALL NONPOINT Issued by: WORKS Dale
s0U GUL S.
a
Sig re.fA plicae vecRe-roofs
D w tor
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Nc epplicam or future building acupem 4orc or handle haurdous material
as dcaned by the Cu amnia M W I Co nc,Chapmr 9.12.and the Health and Safety
❑
k.Scrti.n zsslz(a)7 All roofs shall be inspected prior to any roofing material being installed.
Yes No
Will thea licanl or future building Occupant au If a roof is installed without first obtainingan inspection,I agree to remove
Pp g p equipment car devices which P g
coil hayardo"air contamipap55.aedafnrd by the Bay Area Air Quality Management all new materials for inspection.
District? V�bT
❑Yes ❑ u
1 have read Ne havardoi amamrials mquimmcm underChapwr6.95 of dte Califor-
niaH"Ith&Safely Cod• atJJe ns M5,]5533and25534.1unaemandthal Wilding
does not c n0y aw I(k Nat h b my responsibility m m, i the.up. Of the
rcquiro rut hic mus, npdorwbsuance ic 0ca r currency.�s� Signature of Applicant Dale
ower ,'N. .<aasra D,m All roof coverings to be Class"B"or better