04040137 CITY OF CUPERTINOP+ss* if7.z`
BUILDING DIVISION PERNIIT z.CONTRACA'TaRUNFORMATION
,fiv."u( v+ &? !Yn.+?.:k_-.z_' 'fl�'`u-.
BUILDING ADDRESS: RUDO H & SLETTEN INC PERMITNO04 0 4 0 13 7
19091 PRUNERIDGE (BLDG 46
PERMIT Issue DAT'e
OWNER'S NAME:
HEWLETT PACKARD 989 E HILLSDALE BLV 06/15/2004
E SANITARY NO. CONTROL NO.
(415) 572-1919
ARCHr1ECTlENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
] LICENSED CONTRACTOR'S DECLARATION lob Description
I hereby affirm Nn 1 em licensed under provisions of Chapter 9(commencing p
who Secccind U)of Division3ofthc Busincas erb Professions Code.roti my licenscis REVISION--IN HOUSE USE ONLY
In full force and effect,
5'�z License Class Lk.g NO NEW PERMIT ISSUED ORIG#k03060062
n Dam TSDE L
ARCHI'fECo DECLARATION
1 understand my plans shell W used as public mcnNs �a
� U
3 G Licensed Pmfeuinnel C
3 OWNER-BUILDER DECLARATION Q
I hereby
maso affirm Na,1 1. exempt from the Comms Co License Lew for the -A
0 0
which
mason.(Section 71131.5,Business, lmr. and Prnfcuiuns demolish.
Any city s county V
$ which require a issuance,els it)re cores the Clten impmw,h permit t nr repair any awcmm
pdo m its ensedalso requires theishoapplicant for such permit m.a signet statement
phpmi
that he is licensed wm•antwthe rm.i+ioM nr,rte cnn,acmr•¢unn><Law(cn.ptcry Sq.FL Floor Area N JOCZValuation$31
KFg (commencing with Sution70W)of Division 7 of the Business and Prmmasions CodO)Of
that he is exempt Nemfmm and the basis for the singed exernption.Any violation mf
Section 7071.5 by any applicant for a permit ubjecum,he Applicant A civil penalty of Number Occupancy Type
no,mom than five hundred dollen WED). 3�6 U 7046 . 0 0 .
0 1,as owner of the pmp.rty,Or my employers;with wages atheir aolc compenulion,
will do the work and Me structure I,nut intended or offered for slide(Sm.7000,Business Required Inspections
and Professions Code:The Contractors Lt..Law don not apply to in owner of 9 P
property whobeiIN or impmvu chicon.endw u doe¢such wart w aflIfo lthrough hh
h.e..loy Wiprovided the,such imp mvemanu tie notinten f c m Deere,fmule.IL
builder the five thl uImprovementis veldwithinoneyeti ofcompletion,theOwner-
builder will have tite burden of proving ca,he did not build or improv for purpose of
.In .
1,as owner of,he property,em exclusively contracting with licensed convectors in
o met the project(Sec.Trials,Business and PmfsWons Crede:)The Container's Li.
cense law does no,apply to in owner of property who builds or improves Memo .and
who contracts for such projects with a convector(s)licensed rumen,in the Contrutprs
LicensetARIEW-1
❑lun .BIJ,PC fore cis myonmer DeCOMPF.NS ION DEC
I hereby alrmn under penalty of perjury mantras following declarations:
haveend will mainuin aCenifinte of C.nsenuo selGiuum for WorkersCompen-
ution,as provided for by Section]700 of our LOW,Code.for the performance of the
work for which this permit is issued.
0 1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of the labor Code.for the performance of the work for which this permit is issued. '
My Workers Compensation Laurence carrier and Polity number em:
Carrier. Policy NO.: '
CERTIFICATE OF MEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section reed not he completed if the permit isfoonc hundred dollars(SIM) -
orlcssJ
I certify cot in the performance of the work for which this permh is Issued,I Nell not
employ any person in any manner an as to become subject to the Workers'Compensation
Laws of Calif mils.Dem
Applicant
NOTICE TO APPLICANT:IL sAcr making this Certificate of Exemption,you should
become subject in the Workers CompcnsNon provisions of the labor Codc,you const
�Z forthwith comply with such previsions Or cis permit shall be,deemed revoked.
zO 'ONSfRUCDON LENDING AGENCY
[-w (hereby affirm ca,them isaconstruction lending agency for the performance of
(Y.7 Me work for which his permit is issued(Sec.3097.Civ.C.) ¢
Ie1 Q Undoe's NOW.
tL Ienderi Address
U0 i certify cu I burst read csun
is application and m stthe above infomatiun is
Ik.E correct I agree to comply with All city and county oniinances and sure lava relating to
C) building construction,and hereby anduire mixnsemutim of this city utenter upon the
Li) above-mentioned properly for inspection purposes.
(We)ag a to ave,indemnify rod keep hay in say
the City of Cupertino against
Ilabilitin,judgmenu,eo¢u and expenses which may in anyway eecmc ageins,said City
O ,neon the this
PLICA UNDE ANDS ND WILL COMPLY WITH AL�NO -POIbD' Issued by: Date
SOURCE LA 0 l(9-CC ,
Re-roofs
Si um of Appli an on -con
Dem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Me applicant lir fuwrc builJing uccupenumrc or Mndlc ha' ons material
efined by the Cupenino Municipal Code.Chapter 9.11,and the Health and Safety
rete.Section'55" )? All roofs
Dy. *No 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
hnvardous air contaminants as def rad by the Bay Arca Air Quality Management all new materials for inspection.
iatric,?
D Yes AN.
1 have mW the hmNcros mou riahrequimmenu under Chapter 6.95 of dm Califon.
maHcalth&Safcry o4.S.-o.25SU5,25533.d25534.1.n&.Mdthuifft building
Jens not cumand awe te ani,stet',is my rnponsihility to notify the occupant of sic
miptirementsw tit met missuanceofa Cerufamof Oce yan .
6 17 D Signature of Applicant Date
ow orau,h rued ant 1 Da,. All roof coverings to be Class"B"or better