04120081 CITY OF CUPERTINO §} * W,10EP1 7
BUILDING DIVISION pL�`MT YV, VV *ri'•* z - - - -
-
VAI'
BURRING ADDRESS: - RUDOLPH & SLETTEN INC PERMITN"04 12 0 08 1
19091 PRUNERIDGE AVE
-'NER'S NAME: PERMIT ISSUE DATE
HEWLETT PACKARD 989 E HILLSDALE BLV 12/13/2004
P ONE: SANITARY N0. -' - CONTROL NO. - -
(415) 572-1919
ARC HITECTIENGINEER:: BUILDING PERMIT INFO
eLDGO ELECT l� PLO MECHO
1.+�0� !., LICENSED CON7RACIOR'S�D DECLARATION - Job Description
I herb m Nal 1 am Ilcenad udlor was of Chapur 9(commencing
with don ),olDividon 3ofthm Bud fealeas CaM,amdmylicmais _
mml� ucp -Ty; 3 REVISION--IN HOUSE USE ONLY
LiceSz Dow .e. NO NEW PERMIT ISSUED/ORIG. #04110151 - -
w Dau Contractor .
Ao swan son DECLARATION
'p� 1 undcntarrd mY camas dull he uatl u7mMic rdmda
OWNER-BUILDER DECLARATION
i�I Thereby afRm that I amexempt from the ConuacmM1 License Law for the .- -
0 o foluwing reason.(Section 7101.5,Buinesa and Profodons Code:Any city or County
na� which require a permit to Oman=,.due improve,demolish,lir repair my urucuro -
h,z�' prim an its issuance.atm require,the applicant for such permit to file asigned Moment
ggFFF< Nu he is licensed pursuanm the provisions of NC Conuacmr's License Law(Chapter.9 Sq.FL Floor Area Valuation '.$0
3$ (cammeming with Salon 7000)of Division3of the Budneamd Paumaloas Code)a,
3
that he is eumpl therefrom and the bub for Ne alleged co mpalon.Any violation of
Sado.7031.5 by any applicant ran a permit subjects do,spplkant as a civil penalty of APN Number Occupancy Type.
not mom than f.o hundred dalars($500). 31607046 . 00
❑1,u awrcr of du pmpmy,m my.aploy=WILh mgu u their mlecompenudon, _
wllldo the work,and the structure is notmunded o offered forde sm.7044,Business Required Inspections
-
uW Prefeadoas Code:Ties n cot apply a
e Cors License I.w doan awnes of e 9 pec
property who bulldsorimprowidammon;andwhodommelt work himselforthrough his
however.the bu,PmvlorI Nu aahimprowmeptt uemlmuMedmaRemd far awa,
however,the building oNmprovemaNs cold did an year of completion,The ewe r-
bald.sum haw tit burden of proving Nal he did no haild as impure for purpose of
ask.). \
1,a owner of the propeM,am exclusively contracting with Ii¢need contrxcmn to -constructLo the project(Sec.s an Bus of i and 9efnsioas Code:)The Commerce's U.
ceaselawdaar suchapply r ban with. stomper(whis cemundda or.,tows Corunones
Lwho isma nLacts for such mak.a with a cwnwetar(s)llaased punuant m the Convantota -�
01 am Law.
❑lam exempt undo Sec. .BB PC far Nis -
er Dau
WORKERS COMPENSATION OEC1.4RATow '
I hereby afion under Penney of perjury ore of Ore fallowing dectsmams.rjv - - -
❑I haw and will maintain a Cerditnmof ConmmmulRim M far Warketa Compen- - — -- -- - '
sation,an provided!o by Section 3700 of the Labor Code.for six performance of the
work for which this permit B insured. -
❑1 haw and will maintain Workela Compeasaron Iwrmce,a required by Section
3700 of the Labor Code,for the performance of du work fm which this permit in Issued. .. ..
My Weraces Compeasadm Luunnce copier and Policy number are: ...
AlicyNo.: GKRS
q 7e o'r RFlCTEA . NP
COMPENSATION { NWEOR
(Mi.acre nand hat be completed If the remit is for one hundred!dollar(5100)
or ku)
I mnily that in Ne perfomenm of dm wark fm which this pemi,is warned.l shall net
employ any Mason in any meaner an u in became subject o the Workers'Compensation -. - - -
Laws of Cdifomis.Dau
Applinm ._
NOTICE TO APPLICANT:.If,afar malting this Cer ifutata of Emmption,you should - -—
became subject to we Workels Compensation pmvisimu of Nd LAW Code,you mum
,J O faMwith complymemed coked
with such provaswas or Nk peltshall be deo .
vim~., CONSTRUCTION LENDING AGENCY
F•t I hereby aNm that dere is a comUucdnn lending agency for the Performance of
Osi ti the work for which this permit is Issued(Sec.3097,Co.C.)
lel Q Undoes Nene
U Z corrects Address
U Q 1 Cattily IC 1 haw mad this application and sou that the show information is
Ig, Wilda I agra to comply with all city and dourly nminumer and saw hen miming e
0 rU" Wi
ldingconstruction,and hembymNodmrpose&representatives of this city menta upon the
hwvrmentiu im in save for lemnify n kmp hs
(We)agme s.cows indemnify and kap hay in m the City of against s ld City
U iliabilities.osuenec onW cutsand eapcasesmit, may in any way acme agdasl WO City
V APPLICANT UNDEof the RSTANDS ANof this D WILL COMPLY WITH ALL NON-POINT Issued by: Date .
SOURCE REGULATIONS.
Z't yn' Re-roofs
Si of li Cor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ota applicant or future building mcupat sun mhendle harallom material
as dented by the Cupertino Municipal Cade.Chapter 9.13,me the Hadth ad Safety
.Sectio 355334)? All roofs shall be inspected prior to any roofing material being.installed.
E]Y. XNu
Will the applicant or future building occupant can equipment or dcvims which If a roof is installed without first obtaining an inspection,I agree to remove
emit haardau air contaminants u defend by the Bay Arta Air Quality Monati all new materials for inspection.
District?
oyes �Nu
I have mad the h.udmsmauriats requirememstmarChapur03of Ne Cat
nu Healthd•.Seery Code,Sectiou35505,35533 ad 35534.1wro mund institute building
does me currently have a tenao,that it Is my rem oulbimy in turfy dc occupant of the
mqui mcntswhichmum hemm rmiaaaWar cg of OC Signature of Applicant Date
2_/ ref All roof coverings to be Class "B"or better
Qwficr or new riled a m Dau