05010048 CITY OF CUPERTINO �,+ '+' *��.assa �} yk^ +'s�^sa�3m`y�'�" . y»�'�
BUILDING DIVISION - PERMIT C64\°A�I:eITOl[�Nl O�RMATI01\v '
BDILDINO ADDRESS: RUDOLPH & SLETTEN INC PERMIT N105010048
ER'S NAME: FBRMTTISSUBDATB
HEWLETT PACKARD 989 E HILLSDALE BLV 01/25/2005
ONE: SANITARY NO. CONTROL NO.
(415) 572-1919
ARCHITECT/BNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
(� 0
300 uChat I amCONTRACTOR'S derp DECLARATION Job Description
1 1 ion 7 affirm that I am Hamed under provisions of Chapter 9(commencing P
with Section]IXIU)of Division 3 of the Business and Professions Code,and my license is '
�N infull faandeffea. REVISION--CURTAIN WALL/ELECT PLUMB
Lkme enm i 9r�oG 9 /
i Dam t Contractor TIME BASIS/FEES IS SUBJECT TO CHANGE--PER POH
e
ARCHITECT'S DECLARATION ORIG. ##03060062
L < IunderatanJ my plans CHIhewed as public mils
two
yo Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License law for the
tom 5 following moon.(Section 703 1.5,BYSiaas and Pmlessions Code:Any city or county which requires a Perth to construct,alter,Improve,demolish.or repair any atomism,-Zto prior to its issuance.also requires the applicant for such permit o file a signed statement
that he is licensed pursuant to the prevision.or the Conuw:mr'a Licenm Law(Chapter 9 Sq.Ft. Floor Area Valuation
2 $ (commencing with Section 7")of Division Sof the Business and Professions Code)or po
u that he u exempt therefrom and ft buss(or thealleged exemption.Any violation of Y
Section 7031.5 by any applicantfor a permit subjects the applicant to a civil Penalty of APN Number Occupancy Type
not mom than five hundred delta.($500). P y YP
❑1.u owner of the property,or my employee with wages As their sole compensation,
will do the work,and the sumv re is not;runced or offered for sale(Sue.7044.BualM..
and Professions Cock:The Contractor's Licenm Law does not apply M an owner of Required Inspections
property who builds or improves tenon,and who dassuch work himseHorthrough his
own employees,provided that sah improvements..at inteMed or offered for sale.If.
however,the building or improvement is sold within one year of completion.the owner-
builder will have the burden of proving Nu he did not build or improve fa puryou of
sake.).
Co 1,as ower of the property,.Business c¢lusiv nd)omn):ng Cid:)The )antrseton i.
construes d project(See.]Gad,wnerand property
who bus Code:)The COnuacmr. n
ams law dao not m Su owner of property whe sed p or improves Nemo.,and
Lwho iam. race for such pmjccu with acontnctor(s)liamed pursuant to the COnuanors - a
License exempt
❑lam exempt under Sec .Bg:PC for this reason
cr Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury oa of the following declarations:
I have and will maintain a Certificate of Coucnt to self-insum for Workers Compere
sation,as provided for by Section 37W of the labor Cade,fa the perfonnma of the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,As;required by Section
3700 of the Labor Cede.far be performance of tle work Or which this permit is Issued.
4 My Workers Compensation Insurance artier and Policy number am:
Carrier: '-tLAZ(C.H AMI`ZICA"�aliryNo.:Akl G 34-7S315 -66-
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE LD(p 16 il 3'ta0y(This station need no,he completed If the permit is for one hundred dollars T$100)
las)
1 certify that in the performance of the work for which this permit A issued,I shall not
employ any person in any manner m As in become.object to the Worken'Compeusti n
Laws of C.Hro oia.Data
APPlicam
NOTICE TO APPLICANT.If.after making this Cenifmau Of Exemption,you should
become subject m the Worker.Compensation previsions of the Labor Code,you must
7=O forthwith comply with Such ProviSIOM or this Permit shall be deemed revoked.
.� CONSTRUCTION LENDING AGENCY
I hereby affirm that then is construction lending agency for the perfurmana of ,
1x the work for which this permit is issued(Sec.3097,Civ.C.)
Q Lenders Name -
7 z Lender's Add.
;J Q 1 eenify that 1 have mad this application and suss that the above Intonation is
1.(~ cpnea.1 agree to comply with all city and county ordinances and state laws totaling m
'U bbOv.-aeonstradpn,and hetobyamheritorpose.representatives,of this)sty reenter upon Ne
W shove-mentioned pto save Ter lupecdon purposes
tig)y (We)agree judgmets,nve,;ndexpenses Whify And ch hanlesn NeyU(m Cupcnst midno sty
h ist
ncosequen.or ts,coststhe ,an and expenses Which mainanywayseem.against acid City
in canto exec e(thc �
9 gr TAN of this per mit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
� SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
Signature of ApplicerDDau
HAZARDOO US MATERIALS DISCLOSURE Type of Roof
Willy capp:catnor
future buildings.Chapter re or hanand Health And Safety ticfiSed by the Cupertino Municipal Lode.Chapter 9.13,and Nc Health anJ Safety
. C es 2ss3z(.)7 d0• All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or future building occupant on equipment or dcvica which If a roof is installed without first obtaining an inspection,I agree to remove
mit hanrdous air contaminants As defined by dtc Bay Arca Air Quality Management
Dhanc,7 all new materials for inspection.
❑Yes Nd
Lha a
ds mauriaismquimmenuunder Chapur6.95afthe Cal;(DC
ria Hale cu25N)5,35533md2553a.lundeawdthnildu Wilding
Jas not c drat,WI it u my mapensibility m notify Ne naupmt of Nc
nyuinm nu hit IpdonoiuuenccofeCcnifi roof apan)r.' Signature of Applicant Date
• ower art as Date All roof coverings to be Class"B"or better