04120157 CITY OF CUPERTINO, - •^'*_�.a. gY^ �ya,� `/y 'Ff
BUILDING DIVISION PEl\1Y11T CO !'i 1lHCQ "Y .0�1�16JalRATuI/I� ,
BUILDING ADDRESS: RUDOLPH & SLETTEN INC FFEMIT N004120157
19091 PRUNERIDGE BLDG 46
OWNER'S NAME: PERMIT I55UBDATE
milk HEWLETT PACKARD 989 E HILLSDALE BLV 12/22/2004
E; SANITARY NO. CONTROL NO.
(415) 572-1919 '
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH_
p 0 0 0 C=
am'z LICENSED CONTRACTOR'S DECLARATION lob Description
I 1 bemby affirm that 1 me licensee under provisions of CMp er 9(commencing
wit Samoa 70170)of Division 3 of the Business and Profession Code,oral my 11'.1.
in fail force and effect. REVISION- -RESTRIPE (.E) ACCESSIBLE APRKING
AgS Dam'aCl"' Cataracts, NO NEW PERMIT ISSUED/ORIG. #04060130
ARCHITECTS DECLARATION '
I understand my plan shell W used as public records,
'30 Licensed Professional -
OWNER-BUILDER DECLARATION
E 0 S I hereby.(firm Nal I em exempt from the CaavactCo Licence City
O for the
O o following reason.(Saito conal Buainns and Profusion Cade:Any city m county
'us.$ which mgmms•pemit re cores ft Blur,improve,demolish,t nr repair any strmwm
prior mits iuosnee.atsu requires the applicant for such permitmfile•signal statement
< that he is licensed pumunt to the provision of the Commove,Limns:Law(Chapter 9 Sq.Ft.FloorArea Valnatlon$35--- --
$ (commencing with Smdm7000)of Division 3 ofBusinessand Pro(essimct Code)or
�.. that he u"tempt themfrom,and de buts fm the alleged exemplloa,Any vIolNnn of -" ^
SeNon 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number . _ _ . Occupancy Type ---- - -
amroam than Ev9 hundred dollars(3300). 31607046 . 00
- pl,uawmrofthepmpNymmyanployeowtlhwgesudeksokcompenudon.
will do lhework,and nhesauaure lsnotinundedaro0eted(oraak(Sec.70th,Business Required Inspections
and Profession Code:The Conaacm's License Law docs Out apply m an awns,of q p
property who Ndldsm impmwtleremandwhodoessmh work fountains Waugh his _
awn employees,provided that such improvements are notinuMW moOered for sale.If. -
however,the building or improvement is sold within am year ofcompletion.the owmr-
builder will he"de bument of proving Net he did not build or improves for purpose of
;11
awns,of LimProject
Smpeny,am exclusively and convecting with )Th ed nflact e- i- -
comima de es not (sec.o an, Business and property
who n code:)The CmaamM1 and, F
Li-
come dew don r such
Pro je to owner of property who healss or improves Comm,and, \
who contracts Lace fauuch proFcu WN a emuanor(e)11¢nsedpuuwm 00the ContraaoYa v
lice wa Law. : '
❑I .BkPCfar than reaann -
Dat L_2-12
I ERS COMPENSATDN OECLARA�TI�O/y _
I hereby affirm under penalty of perjury am of IM(A oww &aeclarWme:
hew and will melnuin a CCNOcomof Camara o sel&Insum for Worker's Comport.
utian,u pomidul fm by Saban 3700 of the Inbar Code,fm the pedom ice of the
wok for which this permit is issued.
❑h have and will maintain Workers Compensation Ir homm,as required by Section
3700 of Na Labor Code,for de performance oflhe work for which mupermitisiss.ed. - '
My Workers Compensation Insurance canis and Polity number are: ---
Center: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE
(This action need net becompleted tithe pmmit is foronchunareddol an($100)
or leu.)
1 certify that in the Performance of the work fm which this Perron is issued.I shell not
employ any person in any manmrso at to became subject no ane Workeri Compernamn
Laws mf CeB(amla.Dau
Applicant
NOTICE TO APPLICANT:If,afmr making this Cenificeu of Exemption,you should
become subject to the Work&.Compensation proviskm of the Labor Code.you most
.,O forthwith Comply with such provision or this Permit shall be dcemed rewind.
zy mhCONSTRUCTION LENDING AGENCY
Ibey air.. them is.mosmatim lending agency l'or the p uraounce of
7 the work for which this permit Is issued(Sec.3097.Civ.C.)
QLenders Nam.
Leader's
z,
V 0 1 certify that 1 have mud this application and sum the th.show io(mouUmn Is
D. Correct.l Agree to comply with all city and manly ordinances and sute laws mddng u
0 SV^ building construction,and hamby materim mprelmWivrs of anis city m toter upon the
W above-memknCd pmp.rty for inspection purposes.
gy (Wes)agree in save,indemnify and keep bermlus the City of Cupertino against
n.i h liabilities,judgmcnu.coact and cxpensu which may in my way Gene against old City
C)
ca(the rantingo(thifporml.z APPLI TANG WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU E REG TI PI .
Re-roofs
um ppl'" ant DO
AZARDOUS MATERIALS DISCLOSUR Type of Roof
WIII y t applicant or forum Wilding=upset tom or haiWk h Health and
u de0na by the Caperton Municipal COM,Cheerer 9.11,and tie Health end Safety
Cod.,Section 11531(x77 All roofs shall be inspected prior to any roofing material being installed.
❑Yes 04'N.
Will the applicant or rutum building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hnardous air comumimanta an de0ncd by the Bay Area Air Quality Management all new materials for inspection.
urin7 I
Oyu IYffiII—._
In sovc mad the huardous materials requirements underehapur 6.95 or the Califor•
rolaH.Iu&Sacty Cadc,Sadon 25505.15533uu11553<.lundersunduuirdn Wilding
doss at cnet i B my msponibility u amity de acupanl of the
require nu mu an4 nortoluummoaCenficaeof GCcupanrycy Signature of Applicant Date
tz:-
Ow+_qC.aVhWxd'&j'c'nr Dam All roof coverings to be Class "B"or better