03090108 CITY OF CUPERTINO < e
B 1, NG,VISION PERMIT CONTRA T�(1RTN ORMAT14N
rBmLDINGADDRESS; RUDOLPH & SLETTEN INC PERMIT NCO 3090108
091 PRUNERjnCF. mg
NCR's NAME: 989 E HILLS'DALE BLV PERMIT LSBUEDATB
,_y H P. (BLDG #46 1 2003
)'HONEi (415) 572-1919 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
G7
loo LICENSED CONTRACaOR'SDECLARATION
bar
EE I hereby affirm the,vis 1 am licensed unser add
Poona or Chdpm,9(commencing lob DesCrlpllq,n,�
tofullf.Me70f0).f Division3 of Ne Business and Profcssiem Code,end myliccnao is FINALED
m tan roma ens erten. RER00 F
License Class Lic.M '
,t-n Dam Contract., (ORIG. 403060062) APR 2 2 2003
ARCHITECTS DECLARATION
M
u I understand my plans shall he used as public records
cE
A. Licgn JPmfessional BUILDING
y g OWNER-BUILDER DECLARATION ConamON
2 0 f I hereby.Scc that 11. exempt from the Contras CM License Law cot me
w O following maven.(Section 703 1.5,Business and Professions Codc:Any city nr county
s$ which requires a permit na ennslruct,eller,improve,demolish,or repair any svuctum
prior to id,issuance,also requires the applicant for such permit to file a.cigned statement
z< that he islicensed pursuant 10the pmvismasofthe Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
fit$ (commencing wi th Section 7")of Division 3 of the Business and Professions CnJc7ur
Or 3 Nat he is exempt therefrom and the basis for the alleged exemption.Any=o $0
Section 7031.5 by any applicant for a permit aubjcns the applicant to a civil penalty of APN Number Occupancy Type
no,...domfivehundred donem(s50o). 31607046 . 00 p y YP
❑1,as owner of the pmpeny,or my employees with wages ss their sole compensation,
will do the work,and the swnure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractors License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such on pr.vements Am not inmaded or offered for sale.If.
however,Ne building or improvement is sold within one year of completion,the assure,
builder will have the burden of proving that he did not build or improve for purpose of
sale..
I,as owner or the property,am exclusively contracting with licensed contractors to
con tun the pmjen(Sec.7044,Business end Professions Code:)The C.mracmr's Li-
cense law does not apply to an owner of property who builds or impmwx themon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑lam exem der Scc .B&P C for thhir/iis mason
,her Date u In
WO KER COMPENSATION LARATION
-1 hereby affirm near penalty of perjury one of the following declarations:
FI 1 haw and will maintain 3Certificate of Conacnt to self-insum for Workers Compen- t
cation,as provided for by Section 3700 of the labor Code,for the Awfommnce of the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation insunnce,az required by Section
3700 of NC labor Code,for me performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number art:
Cartier. Policy Na.: _
CERTIFICATE OF EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE
(This section need not be emni leted if the termit Is fraud,hundred dollars($I W)
nr less.)
I certify that in the perfmmanee 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 Workcra Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,arta making this CDnlEcme of Exemption,you should
became subject to the Worker's Com penmtion provisions of the Labor Code,you must
Oforthwith comply with such provisions or this Permit shall he deemed revoked.
CONSTRUCT]ON LENDING AGENCY
1 hereby off rm Nat them is a construction lending agency for the Performance of
x > the work for which this permit is issued(Site.3097,Civ.C.)
Q Lenders Name
z LendersAddress
1
Q 1 certify that 1 have read This application and stem Net theand
above information is
y U building 1 agree m comply with all city and county ordinances ens state laws relating e
�fJ alhow-melding nioned irn,and herebyhuhrechorimron posesematives of this city mcmer upon 0c
N a shove-mentioned to ortysave find n urfify add ked ha
ti esju agme m save,indemnify and keep hay in an the City accrue
Cupertino against
inconsequnce cA the
sang of thisexponesmit. may in anyway accrue againstaaiO City !yam
inconsequence the graining of this permit. ffV/ffl to
" APPLICANT DERSTANDS A WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RE TIO S.'
u 4e-roofs
5'g mac of Applica C. DDate
AZARARDOUS MATERIALS DISCLOSURE Type Of ROOF
Will the applicant or future buildinge,Chaptstarem and the
Health and Safety as dcfined by the Cupertino Municipal Code,Chapter 9.12,end the Health and Safcty
40or.cown25532ta)? u All roofs shall be inspected prior to any roofing material being installed.
V.
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 hoxardnus air contaminants as dcfned by the Bay Area Air Quality Management all new materials for inspection.
Dieviet] f'
❑ �
Yes <N-
I have mad the havardous materials requirements under Chapter 6.95 of the Cal for,
ria Hcahh&Safe Cotle,Swcons255O5.25533ud2S534.1.ndemandthotif Nchuilding
Jeea a v'u y have a an4 Nat i is my mip.naibilhy in notify the mmupant or the
Mgmrcments hi sl t ,idea cenfaCeniIII loci ancy. I ygag[UTeOfAppllcant Date
Dam All roof coverings to be Class"B"or better
net or authorized km -