04060130 CITY OF CUPERTINO nIr: +*
BUILDING DIVISION PERMITCON�T2AC�+TOR�INFOP.MA'I'I ON �l
BUILDING ADDRESS: PERMITNO.
RUDOLPH & SLETTEN INC 04060130
BT.BG 46 OWNER'S NAME: PERMIT ISSUE DATE
SANITARY �ftOL 10.
IARC7H[M��GINFER: BUILDING PERMIT INFO
BLDG PLUMBMECH� 1�OLICENSED CON2RACTOR'S DECLARATION
UI arcby affirmNallamlicemcd under pravisiam of Chapter Y(rommcncing Job Description
Section]IXllpof Diva.hm of Ne Businessand Profcssinm Code,and myliccnsatsl rase¢and effect.ib anrcS�ylausa LM.s TENANT IMPROVEMENT-SEISMIC UPGRADE
Dam SYI.M Con—ECL
,e SIT A LTSDECLARATION FULL FLR BUILD OUT
y I mMe.nnd my plana mall be tied a public recnNs
Dy
LLo Licensed Professional
OWNER-BUILDER DECLARATION
f I hereby efforts Net 1 1. exempt form to Conuacmfs License Law for to
0 0 which ng teres a Permit t IID IS,Business anderr Pro@¢loin Code:Any city or umclum
which is ishu...Amit to romuvet,aline Applicant
borrow,h .iiM1,or repair any tater. a
Fid^
poor lnslieu ed puramm to the the
ovisios of far Contratois o fila Lkmn Law(Char cm
that aincint,ed Purwant todeof Division
of Nc Conuumfand Proflsw(Capter9 Sq.F[. Floor Area 4_5V➢000
$ that he I.
exam its Section]000)of basis for of the Busaged exemption,
on,myons COCA)or b U U
Net a u exempt therefrom and the Ensu far the alleged esempuw.My violation of
Section 7031.5 by any appgesmfor a permit subjects the appgcant10 a Civil penally of APN Number Occupancy Type
not more Nan five hundred doll..($500). v
❑1, As
a MAU of to lemputy,or my employees with wages As their wit compensation, 31607046 . 00
will do the work and the anchor Is not intended or offered fo...le(SCC.]Dda,BnamAxA Required In e
And Professions Code:The Camnemfa License Law does not apply to an owner of q
property who builds or improves thereon,and who does such work himself her thmogh his
Own employes,provided that such impmwmcnts art not inended mortared for sale.If, • `sv
.waver.NC building or improvement enofMoving mid within one year of c prove f r ma owned - ? ?O C®
builder will have to burden of proving Nn a did not Wild or improve for puryose of
sale.).
❑1,as owner of the property,am exclusively And c0nuaering Cwithod IleweC contractors to /� 0
come La dm ca not )See.toad,Business and ty wh i Wilds
Cade:)The m the Contractors nd ® L`
came Law dote not apply e an owns her property who Wilds or impreves there..,and
wW
License
Laces for such projeeu with aeonvaetor(.)licensed punuem m Nr:Conusetoh
License Law.
❑lam uempt undo See .BBPCfar Nis mason
t37W
r Data
WORKER'S COMPENSATION DECLARATION
1 hereby aRtm under penally of perjury one of the following decimatiom: .
raw and will maintain•Cardfienm of Consent to sclf-insu.for Waraf.Compen-
n,u provided for by Section 3]Bo of the Labor Cade,for to pertannance of the
for which Nis permit I.issued.
haw and will maintain Workefs ComPenell0a Imm�nce,u required by Section
of to LaWf Code.for de performance of tie work far which Nis permit u Issued.
Workyer's Compensation lnsunnce carrier and Policy numbberam:nPOAA, �f R C2_•_ ALn SAM icy No.:CERTIFICATE OF EXEMPTION FROM WORKERS'
✓ (Ae'kt COMPENCS/ATION INSURANCE (��^(
ITMSe llmrce mirlLirthe MornitlslmonchuM.A ft
_
or Mss)
1 certify that in the performance of the work for which this permit is human,1 shall not
employ any Person in any manrerm As to become subject in to Worken'Commasauan
Law,of C.HrOmiL Data
Applicant
NOTICE TO APPLICANT:If.ofer making Nu Cenificae her Exemption,yore should
become subject so de Worker's Compensation provisions or Ne Labor Cede,you muse
.,0 forthwith comply with inch lu., ism nr this permit shall be domed evoked.
z CONSTRUCTIO N LENDING AGENCY
[+ Ibertby affirm Nat rhes I'."T's—ti..
lending agency fm Ne per(urm"m of
E ti, he work fur which this permit i,issued(Sec.309],Civ.C.)
B7IsIWLfs Name
0,Z ILnder'1Address
U O I.entry that I hers mad this applimft.end state that Ne W.infmosti ma is
VL F correct I ague m comply with all city and county ordinances and mute laws relating m
DU building.onsnction,and hereby numorice represcmalives of this city m enter urns to
W aave-mentioned propeny for inspection purposes
y (We)agree Ire saw,indemnify and keep momless the City of Cupertino against
A2 liabilities.judgments,costs and expenses which may in my way aecme against said City
U Z in consequence of the granting of this.Grind.
APPLIC UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Da
SOU C RE M
Re-roofs
0 Applie.YConuumr D
HAZARDOUS )ALS DISCLOSI pP TyPe of Roof
Will Ne applicam her rmom Wilding occupant.mre ek andle ha'rsNous material
m defined by the Cupertino Municipal Cade,Chapter 9.12.and to Health and Safety
cndo
Coca. rks VA/.zss3z25532(a)? All roofs shall be inspected prior to any roofing material being installed.
Yes VAN
.Will the applicant or rruiuCm Wilding occupam use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
havurdnus oI,contaminants Asdefined by the Bay Area Air Quality Management all new materials for inspection.
rict7 a
❑yes Nu
1hawmad Nehma ousmamrialsmquimmenuunbrCapmr6.95orthe Califon
na Halms Safety Cade,Swum 25505.25533 and 25531.1 uncernend that if ft Wilding
s no { v,
does 4- 4tza-
lyL Not itis my rcspomibillty m nobly me mcurant of de
T
requlremictpilar.issuanceofa Certifies.her Decor. Signature of Applicant Date
o henycJ agent be O All roof coverings to be Class"B"or better