03120037 CITY OF CUPERTINO 7- E ie '
BUILDING DIVISION PERMIT �a�ammkq" �p�2 T1Y Q,�A'TIUN
BUILDING ADDRESS: RUDOLPH & SLETTEN INC PERMIT N%3120037
OWNER'S NAME: PERMIT ISSUE DATE
E:
SANITARY NO. 2 CONTROL N0.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LOO LICENSED CONTRACTOR'S DECLARATION JbDescri [ion
(iY I hereby affirm deal 1 an licensed mo er previsions of Chapter 9(Coop
mmmming �,.
n< with Seedon 7")of Division 3 ofthe Business an Professions Code,and my license B,
in full force a effect.
uemn cmomm � iEVISION- IN HOUSE USE ONLY
9 7 ARCHf1ECT1DEC 0 , MIT ISSUED/ORIG. #03060062
nilI tm and my plana¢hall W used as public romods
G S Licensed Pnucssi0nal
^ OWNER-BUILDER DECLARATION
d a y I hereby reaso .(Simi than 11. exempt from Ne Contractor¢License Law for the
O O fallowing mason.(Section 7 o s r Rosiness and improve,
de inm Code:Any tiny or county
K$ which¢quires a permit re conumct,a@r,impmvn,demolish,ore a gg any structure
F�< pdorm iccrosed Inerequires tbeviskar.fthe Ctmoram'tOeo .Lowdsummenl
O thathe(commeslicensedPStct n?000)ofD1osi0n3of Contaccer andPnseomm ChaPmr9 Sq.Ft.Floor Area Valuatien$31
$ (cat he
(commencing rSemfocena0)of Divisiofr th alegeuc desa pon.Anynvi Cede)or
Nat he ts tempi dtemfram and Ne basis far the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit mbjecu the applicant to a civil penalty of APN Number Occupancy Te
so,mme Nan five hundred dollars;(S500).
P y Jp
01,u owner ofthe properly,or my employees with wages star man sole compensation, 31607046 , 00 -
will bo the work,end Neswcmm is notinmboed oronemd foraela(Sec.]014,Business
and Professions Code:The Contractor's Licnme Law does not apply to in owner of Required Inspections
property who builds or improves deamon,end wha does such wark himself or Nmugh his
own employees.Provided that such improaements are notimmaded stuttered formic.IL
however.the building or impmvement is sold within one year of completion,Ne owner
bustler will have tiro burden of proving that he did not Wild of improve for purpose of
sale J.
❑Las owner of thmct Seen ,B exclusively contractingfesswith Incensed cntract es U.construct the project(Sec.7W,an Business and Pm who Wilds
Code:)The Conl merged,
ndcense Law coca not apply b an owner of property who Wilda or improve Norton,and
who contracts for such projectswith a contractor(s)Incensed puravenuo Ne Contractors
License Law.
❑lam exempt under Sea ,B&PCfor this moon
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury one of the following dada bans
llcll-yl�
have and will maintain a CmOftate of Consent to self-inaum for Worker's Camper.
n,v provided(m by Section 3]000(the labor Cade,for W performance of the
for which this permit is loved.
have and will maintain Worker's Compensation InNmnm,es required by Section
of the Labor Codc,for dm performance of tiro work for which this permit is issued.
Worker's Compensation lnsumna cantor and Policy number am:ier: Policy Na; LLXN9530T l
CERTIFICATE OFE.XEMP170N FROM WORKERS' exp IO/1/
COMPENSATION INSURA�
�(Iba ttctlan need not be camp lased if dm perm it is Inn one h unfired dollar(11(1(0
or Ices.)
1 certify that in to performance of the work for which this Permit a issued,l shall not
employ any person In any marl u N become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenifiam of Exemption,you should
become subject to Ne Workers Compensation previsions of Ne lobo Code,you mug
.,O forthwith comply with such provisions or this Permitshall be doomed revoked.
Z Ey CONSTRUCTION LENDING AGENCY
T hereby affirm that Nem is.mrsur nn lending agony for the Performance of
the work for which this permit is issued(Sec.3047,Civ:C.)
0.Q Tinder's Name
Z Lender's Add.
U O 1 certify Nat I lave mad this application and sum that dm above information is
IL correct.I agree to comply with all city and county ordinances and some laws rclming to
U Wilding construction,and hereby someone mpmttnutiver of this tiny to enter upon dw
W above-mentioned properly for impecdan purposes.
C (We)agree to save,indemnify and keep harmless the City of Cupertino against
gn liabilities.judgments.coats and experues which may in any way accrue against said City
in consequence of the granting of this permit v
��
APPLICANT U DERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE EG ATIO
C - �esbv gig a/r y Re-roofs
S
to o pp ian ac
oomtor ate
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building oceupants om or handtc harsreoa memoal
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 255320)?
❑Yes �Nu All roofs shall be inspected prior to any roofing material being installed.
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
it lutm dnue air contaminants as dcOncd by dm Bay Area Air Qualily Management all new materials for inspection.
Dieuict?
❑Yes �Nm
I have mad the hangdousmaterials requirements under Chapter&95 of the Califon
niaHalN&SafelyCode,Section25505,25533 and 25534.1 understand NatifNc Wilding
does nor Connolly hem a tenant than it my responsibility m roomy the mcupent of the
mquirm awhr hmu mel P�grmismananfaccriram fa pant Sig nature of Applicant Date
KDb[nn oidt/ /X/ All roof coverings to be Class"B"or better
wnc rmthcomd agcm (Dam g