05030295 CITY OF CUPERTINO t //°yy"//^��°7��z���'e ^�' tyy+yy"" �ymp��
BUILDING DIVISION pER)�T $VVi\ C4I
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BUILDINCADDRFss: RUDOLPH & SLETTEN INC peaMrrNo05030295
_9nQ1 PRIJNERIDGE AVE 46
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY OL NO.
ARCHITEC fEbIGINEER: BUILDING PERMIT INFO
BO ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION Job Description
rO� I hnreby afOmm that 1 w liamed under provisions of Chapter 9(commercial;
=j NN Soctlon 7")ofDivlaion 3 ofthe Business and proportions Code,and my license is
in full port and e t
yg= 1. at 1 � Le.« ( �$� `1
CoM.101 TI-PATIO RENOVATION-'CAND Lf®
L LI Dam <' �2r...0 + D
,W ARCHITECrS DECLARATION SANITARY VIDEO INSPECT D
1 understand my pbm'hall he used as public records
J
3y,
Licensed Pm(casionel
O OWNER-BUILDER DECLARATION I ZUOS
w
0 SY I hereby nam.(Dem on 1 em momPe from ileac Contractor's :Any c Law for dte
O O following reaann.(Bandon 70315,Business and remove,
do nli Cam:Any city m county
$ which requiem a permit re cores Me Hee improve,h permitsm.or malt any awcturo
__�' pdarmitsiensedp..Set..Me lbe applicant for such Permltmiense Lgmdmtemant
F xx G Nos k is licensed pSwi m to the provisions of the a Bumuca d License law(,leper 9 Sq,Ft. Floor Area O O
havy F thatnmen exempt
with Swim700Mand of basis f r of time Busimssm t on.My
Code)or
Net Ise b exempt Nemfrom and the bole for de alleged exemption.My viohtlan at
Section 70717 by any epplicam for a permit Subjects the applicant in a civil amity of APN Number Occupancy Type
not mom than five hundred dellen($500).
❑l,uowm oftk property,mmyemployeea with wa{mas theirsoleeompesution, 31607046 . 00
wllldo the wick,end the structure is not intended Mattered forsto(Sec.7014,Business
and Professions Cade:The Coaduacm/'License Law does not apply m an owner at
Required Inspections
property who Wilds orlmproem thereon,and who daea'uchwork himselfor through his
owncmploycm,provided then such improvements are notintendW m.fl eyed formic.It.
however,Ne building or Improvement is mid within am year of completion.Ne owear-
bu0der will have the burden of proving that k did not build or improve far purpose of
❑1.as owner of the property.am exclusively connecting with licensed comnctars to
couswet the project(Sec.7014.Business and Pmfeadam Code:)The Cmoactor'a Li.
reuse Law doer not apply to an owner of property who Wilda or hanowa thuman,and
who contracts for such projects with aeanuactor(s)licensed pursuant m the Conmsetar's
License Law.
❑1 am exempt under Sec. .B @ P C for this rmmn
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby alpha under penalty of pejury em of the following decler.tions:
l a.mal will meimsin a Cetifrme of Consent to self.inmre for Warkar'tCompen-
an,as provided for by Section 77W of Ne IaWr Code,for Ne performance of the
work for which it.permit Is Issued.
F7611 have and will maintain Worker's Compensation Insurance,as required by Section
S]00 of the labor Cade,far Ne performance of the work far which this pemtit is issued.
My Warker's Compenaad on Immnunm artier and Policy number are:
Cartier.'*RuaA C.4 PolicyNo.:
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE
(This.9.need not k completed If the Permit is far.hundred dollen($100)
or Tem.)
1 ecnify,Net in the Performance of time work for which this Permit IS issued,I shell not
employ any person in any mannerm as In become Subject to the Wodere'CDomemation
Laws of Califomle Data
Applicant
NOTICE TO APPLICANT:If.after making this Cer iOmte of Exemption,you Should
become subject to the Workers Compensation provisions of Ne labor Cade,you must
.J O foMwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
EI berebyeRm Nn Nem lee commaxann lending agency for the performance of
> the work(err which One permit h isamd(Sec.3097.Civ.C.)
QLemices Name
.1. z Landers Address
C.7 Q 1 certify Nat 1 haw read this Application and man thn the eWve Information Is -
Un F coma.I.Stec a comp) with all City and county odiwxas and State laws misting w
QU building construction, hereby anthodm mpeemnu0ws of Nu city to corer upon Lac
(y abeve-numdamed pro for inspection purposes
(We).grt ,indemnify and keep harmless the City.(Cupertino.grunt
y Ilabiliti dg n umdcxpemmwhichmayinmyw.yaa againissid City
U Z in ca c f ranting a(this permit.
., APPL A STANDS AND WILL COMPLY W oA Q(JON-POINT' Issued by: Date
SOU E L NS. S
Re-roofs
Signatum of ApplionUComnctor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Me applicant or future building occupant core or Mndic Ingenious material
m dented by the Cupertino Municipal Cade,Chapter 9.13,and the Health and Safety
Cade,Section 37533(.)7 / All roofs shall be inspected prior to any roofing material being installed.
❑Yen /$INS
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,l agree to remove
nrdnm air xmMrnInxc u defined by the Bay Area Air Quality Mampemcm all new materials for Inspection.
he m hmmdausmmrials requirements underChaperd.95ofthe Califon7-'C"C0'3ycS
I otic,Sd.255o5.ss533 mM341a.ke dN if&Wiring
no c awameant.NethhmyM1N2! il' mood' Nc accupantofthe
UT w' num be met prior toissuance 'pCee occupancy. Signature of Applicant Date
/ a
owners author 'gem Date All roof coverings to be Class"B"or better
C