03100213 CITY OF CUPERTINO
BUILDING DIVISION PERMIT F. CONTRA�i'aQR INFORM ATTONug:
BUILDING ADDRESS: PERMIT NO.
RUDOLPH & SLETTEN INC 03100213
ER'S NAME: PERMIT ISSUE DAM
qgkE: SANITARY OL 340.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
3a$ LICENSED CONTRACTORS DECLARATION Job Descri tion
1 hereby AMM that I am licmued under pmWsiom of Chapter 9(commencing P
n� with Seamon 7")of DlWalon 3off Busies and Prefummas Code.and my license I.
in full force and effect -
4 Oero m'ler c Claes Lia.4CANOPY ADDITION
ARCHITECTS DECLARATION
I understood my plans shell W used as public records _in
�er3Liccued PmDadeeal
OWNER-BUILDER DECLARATION ( li IFI
I I batch,affirm that 1 em uempi from Ne ContnmpA L ense Law for theSoo following meson.($ des 70315,Business and Profudou Code:Ahy city ter county'a which rtquba a Permit m construct.als Improv,demolish,or 4sIr myrmodewte I
dor m its Waseca,also uom Nes pant for such rmitto file ui ned'summentNatheisncoued Punuen�t to rise pmvnbu of the ConrrMmmra Lk,.dVlaw(CbaPtei'�/ . r Valuation
o marmeming with Schon7080)of Division 3 of the Entinw and P 'essiou�CqEeJqr
$ Nu he ts exempt titerefmm and the basis for ties allegrA aanptioa. a v platiavAf
Seeders 703 LS by arty applkmi fore permit aubjecu Ne applkmt ie my I Penalty of APN Number Occupancy Type
not mom Nan nes hoMted dollars(M).
❑I.ua roof NepropenyamyemploymwiNwaguuth nlec penudon,
wllldotheworkandtheawcumisnotintendedoroRemdforW (Sea.7014,Business 3 16 07046 . 00 Required Inspections
and Professions Code:The Commemrs Llmm law dm rot apply to an owner of q
property who builds or im proves Ihemon.and who does such work hlduedf or through his
own employm,provided Net inch improvements are not Intended orofTemtl ferule.If,
however,the building or improvement Is mid within on year ofeomideccus,the owner.
Wilder will haw Ne human of proving Nn he did not build or improve for purpose of
;ha
a owns of site property,am eac udwly contracting with licensed committees m
met the pmjcct(Sec.7014,Business and Professions Code:)The Contractor's U.
law dm not apply man owner of progeny who builds orimprew dtsecon,and,
warm s for such projects with a conuecmr(s)11wued pursuant m the Communes
ce Law.
amex pt Mat , I&PCfor Ni even
Dau �WORKERS OMPEN ATION EC TION1herebyaffirmunderpe allyof perjury este ofsite following declantieu:
w end will main Wn•Cerdfimm of Couent m self-inure for WorkersCanpen-
urion.u provided for by SttrI.3700 of the labor Code,for Ne performance of the
work for which this perrelt is issued.
❑I haw and will mainlaln Worker,Comperum loo l...as required by Section
3700 of the Labor Cale.for the performance of the woh for which this permit 6Ismax.
My Workers Compasomme W unms:carrier arld Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS*
COMPENSATION INSURANCE
(This maim deed not becutnimded if the Fermis u form.hundred dollan($1M)
m less.)
1 certify Nat in Ne performance of Ne work for which this permit is issued,I Nall not
employ any person in any mmocrm as m become subject to theworken'Compensation
Law s of CW fenla.Dau
Applicant
NOTICE TO APPLICANT:If.miter making this Certificate of Exemption,you should
become subject to the Workeri Compcaation pmvimoa of the Labor Cade,you mum
.JO feMwith Comply with inch Pmvidou ter this Permit shall W decreed rewlmd.
„Z,r.~y. CONSTRUCTION LENDING AGENCY
E-r I hereby affirm Nat Nen Is a coruuucdon lendinS agency for the perfmmadere of
fx> the work for which this permit Is issued(Sec.3097.CN.C.)
(y Qlenders Name
0.a z Lender's Address
(.)Q I esnify that I haw mad Nis appliadon and sues Net the show Information is
It,F" correct.1 alpmC to comply with all city and county ordinances and sum leve reining to
Q building construction.and hemby authodne mpmaenutiwa of this city to enter upon the
above-mentioned pmpeny for impaction purposes.
(We)agree m saw,indemnify cosi 1ttp hannlra Ne City of Cupertino ag time
nF.t 0 liabilides.judgmenu,costs and expenses which may In my way accrue agalmt mid City
U 7 in consequence of the granting of this permit.
�.r APPL A UND STANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU E GU 0 S,
CL!> Re-roofs
I)INIUM of Apple= trmtor Dam
H RDOU$MATERIALS DISCLOSU Type of Roof
Will rico applicant w future building nex upinl mom or handle hmasdoas malarial
a defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
.,cosies 25533(x)?
❑YaAll roofs shall be inspected prior to any roofing material being installed.
No
Will the applicant or future Wilding occupant use cquiPmmt or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It haamnus air cenuminanu as defined by the Bay Amo Air Quality Management all new materials for inspection.
District?
C1 Yen 'Nu
I hive mW We hmardmo materials requirements under Chapter 6,95 of the Califmr,
nice Health&Safety Code,Seetioas 25505,25533 and 75534.1 undenund this if Ne Wilding
dm no,cu ndy hew•tenant Net It is my mapomihilhy m notify the occupied of Nc
mquimWan hi mat a 4raCcrtillceteefoccupancy. Signature of Applicant Date
1 All roof coverings to be Class "B"or better
weer ora ftmed agent Dam