03080113 (2) CITY OF CUPERTINO ''' a
RulLmrvc nrvlsloN PERMIT CONTRACTOR INF0RMATil, '
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BUILDING ADDRESS: RUDOLPH & SLETTEN INC PERMIT NO 03080113
OWNER'S NAME: 989 EHILLSDALE BLV PERMIT ISSUE DATE
RIF"Et (4 15) 572-1919 SANITARY NO. CONTROLNO. .
ARCHITECTIENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a 0 0 0
;Oo LICENSED CONTRACTOR'S DECLARATION
I u I hereby af0rm Net 1 am limnsed umlcr provisions of Chapmr 9(enmmcneing Job Description
with Semion]01107 ofpivision3of the stneesand ProTensions Codc,end myliecnu is
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M 31.❑ "ARAh 1 EC sed aspuuaLARATION
and shall he used as public records '
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Licensed Pmfcsaionel
OatNEurBUILDER DECLARATION
<f 1 naso .('firm on 11. exempt from the Contractor's o License Law for the
pm following reason.(Scniun]113 L5,Business and Professions Code:Any city or county
3 which requires a Permit in construct,alcor,improve,demolish,or repair any structure
�y
pd.,In its issuance,also mquims the applleanlfnf such permit to file a signed statement
< that he is licensed pursuant rothe prnvisionsofthe Contractors License Law(Chapter 9 Sq.Ft. Floor Area Valuation
e50 (commencing with Section 7")0[Division 3 of the Business and Professions Code)Or
Nat he is exempt therefrom and the basis for the alleged exemption.Any vbdul,n of 31607046 . 00
Section?031.5 by any applicant for a permit subjects the applicant to a civil penalty of 'APN Number Occupancy Type
not more Nan Live hundred dollars($500).
I,uowner of the propcny,or my employees with wages as Ncir xolc c0mpcnsalion,
will do the work,and Nnot esummuteisnontendedOrofferedforsale(Sec.7o44,Businesa Re uired Ins ections
and Professions Code:The Contrectora License Law does not apply Io an owner of q p
Property who buildsor improves Wman,and who does such work himself or Through his
vet employmn.provided that such improvements are not intended or offered for sale.if.
liawaver,the building or improvemem is sold within one yeu of completion.he owner.
builder will have the burden of Proving that he,did not build or improve for purpou of
sale.). �\
0 1,as owner of Ne property,am exclusively contracting with licensed contractors to
.consuun the project(Sec.7044,Business and Professions Code:)The Contramm's Li.
c se Uw docs nal apply m an owner of property who Wilds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to Be Commnah
License Law.
❑I so exempt under See. ,B&P C for this reason
Owner Due
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury one of the following declarations: -
I have and will maintain a CCnlEeale of Consent o aelf-insure for Warker's Compen.
anon,as provided for by Seniors 3]00 of the Inbar Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3]00 oftt�e Labor
for
Bey performance
of due ework f wty'ch A�;�i' d. �!a
MY WarArM6Js'nam'+IJInN •�ruer+4+w'tb6rA_tf7 '`,C11Fa .Jy \
Gamer. Po yNa.:_�r, Sul_ o7 "� 3
j CERTIFICATEOFEXEM FIt MWORKERS'
✓ COMPENSATIO SURANCE
(This union need not hccompleted if the permit Is I'mone hundred dollars(SIM)
or less.)
1 certify Not in the performance of the work for which this Permit is issued,I shall not
employ any person in any manner set as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Ccrifoate of Eacm prion,you should
Become subject to the Worker's Compensation provisions of the Labor Codc,you mus
.J$ forthwith comply with such provisions or this Permit shall be deemed revoked.
'Z V)) CONSTRUCTION LENDING AGENCY
'p•u I hereby affirm Nan there is a CaaSIOUCL m lending agency lor the performance of
fYi the work for which this permit is issued(Sec.3097.Civ.C.)
W� Q Lenders Name
D z Lender's Address s,
U Q 1 certify Nat I have read this application and slate that Be shove information is '
cored.I agree to comply with all city and county ordinances and state laws relating to
building eons rection,endhemby eunIn rive represconadves of Nis city la cnmr upon the
,r a above-mens d propcny for inspection putpous.
(W a ren to save,indemnify and keep harmless the City of Cupertino against
uF.0 N houlluej rod costs and expenses which may in any way accrue agaimLcaid Cityronong
V t"^ APPLu AN Nt ERSTAN cgrandfinga As pa WILL COMPLY WITH ALL NON-POINT Issued by: Date r/Y�
SOU ER L ID
Ski 1%1 Re-roofs
S' turco pli JCononcor Dem
HAZARDOU MATERIALS DISCLOSURE Type of Roof
Will6 plicant or future wilding Occupant score or handle hanarduus material
as defined by the Cupertino Mu cipal Code.Chapter 9.17.and Ne Health and Safety
Cade,Section 75532(.)? �/'''ffflll All roofs shall be inspected prior to any roofing material being installed.
❑Yes gnu
Will the applicant or future building accupam use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.'
istrict? `,
❑Y �s'u
1 c a hamrdousmawrialsmquimmcnounder Chapmr6.95of Ne Califon
maHcal &S Cdc,Secdun (15,75533.dM34.1undcm=dNatifthc building
docs not'u he e a conn dual t is my responsibility to nodl'y L,mcu, I of Ne
require nts ch aatbe a do ¢c
r iissuanor Ccoureama cap. * I I Signature of Applicant Date
woe or au aze gDam
'�• All roof coverings to be Class "Bt' or better
rem
CITY OF CUPERTINO
1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 3
Sec : Twp : Rng: Sub: Blk: Lot :
APN . . . . . . . . : 31607046 . 00
DATE ISSUED. . . . . . . : 08/21/2003
RECEIPT 4 . . . . . . . . . : 22873
REFERENCE ID # . . . : 03080113
SITE ADDRESS . . . . . : 19091 PRUNERIDGE DR
SUBDIVISION . . . . . . .
CITY
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : HEWLETT PACKARD CO.
ADDRESS . . . . . . . . . . : 19091 PRUNERIDGE DR
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : HEWLETT PACKARD
CONTRACTOR . . . . . . . : RUDOLPH, ALLEN LIC # 5335
COMPANY . . . . . . . . . . : RUDOLPH & SLETTEN INC
ADDRESS . . . . . . . . . . : 989 E HILLSDALE BLV
CITY/STATE/ZIP . . . : FOSTER CITY, CA 94404
TELEPHONE . . . . . . (415) 572-1919
E ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- -- --------
BPERMFEE VALUATION 488, 000 . 00 2340 . 00 0 . 00 2340 . 00 0 . 00
BPLANCHK PERMIT FEE 2 , 340 . 00 1989 . 00 0 . 00 1989 . 00 0 . 00
BSEISMICOM VALUATION 488 , 000 . 00 102 .48 0 . 00 102 . 48 0 . 00
---------- ---------- ---------- -------- --
TOTAL PERMIT 4431 . 48 0 . 00 4431 . 48 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
------------- ---- ------------ - -----------------
CHECK 4431 . 48 310500
TOTAL RECEIPT 4431 . 48
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
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704 DEMO
*CITY OF CUPERTINO D
DEMO
CUPEkTINO PERMIT APPLICATION FORM
APN # ! G U o / Date: O
Building Address: 2 �
n JA c
Owner's Name:„ Phone#: � _ ru
y 63
y
Contractor: �, � S' �I License#:
Contact: l' P one : 4 3�
12t � M3���„�` � (os DO
Applicant/Contractor
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Buil'din Permit Info:
Bld Elect Plumb Mech.
Description:
Residential: Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation:
Type of Construction: c ancy Gro p: C I
Qty. if
Applica e p \ Fee ID Feee cri tion Fee Group
BPERMFEE Bldg Permit Fees BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
BSEISMICRE Seismic Residential BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG
z2 �- 73
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