05110136 CITY OF CUPERTINO +° ^
BUILDING DIVISION PERMIT 4CONTRACTOR NF0RMATION-
BUILDINGADDRESS: RUDOLPH & SLETTEN INC PERMIT 110.05110136
ER'S NAME: PERMIT ISSUE DATE
HEWLETT PACKARD 289E ILL 12/21/2005
PHONE: SANITARY NO. CONTROL NO.
(415) 572-1919
ARCH1TECflENGINEEK: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
X00
LICENSEDCONnRd underSDECIARf Chap Job Description
U ION
1 hereby affirm that I am of the
Bu under and
Profession
of Code. 9(commencingsis
with Scarce an 4RCDivision 3rf WC Businesvnd Profcuinns Codc.and my license is
in full force and a
L;een ,� � Lk.g 1Q�06 TI-RECONFIGURE OFFC . SPACE/SPRINKLERS
nt-� Da,c Lic.,Computer N MINOR METAL STUD STUCTURAL, REVISE
Y�jARCHITECTS DECLARATION
W U I untermand my plan shall be umd u public records
SW
;Q 17 Licensed Pndcui...I
jg OWNER-BUILDER DECLARATION
.2 1 hereby affiren that I am exempt bum sbe Conuacto's License Law for the
i
00 following reason.(Section 7031.5.Business and Profession Cade:Any city or county
S m which myvirn A Permit to en since,Alter,improve,demolish,or repair any structure
_zy priori iu;ssumoc.antrequires due applicant forsuch Permit to rile asigned statement
< that he islicensed Pumuanuotheprovision oftimCommcmr'aLicenselaw(Chepmr9 Sq. Ft. Floor Area Val$a3i8kD000
i�S (commencing with Section 7")of Division 3 of the 8usineuand Profession Code)or
— that M is eacmpt therefrom and the basis for the alleged conception.Any violation of
Section 7031.5 by Any applicautfor.permit subjects the applicant in a civil penalty of APN Number Occupancy
not more man btu hundred dollar: panty Type
31606033 . 00
❑L u owner of the Property,m is ecepleym with wage u alev sole compensation,
will do Priswork,ands: awmuresme.Licens Lawdosessile(Sec.in aa,Business
and Profession Crile:The ConttaomYs Liana law does ret apply lf an sough,of Required Inspections
property who Wilds i improve thermn,andwho doessuchwork himselfm through his
howown employen,providrdiumvemansuch iceprowceentsarene our of omphorm.for the owner.
builder,Ne building or;mprowmenngsaid within oneyoum mprove fn,pupwa,-
builder will have Ne burden of proving that be did rot Wild m improve Ice purpose of
sale.).
❑L an owner of proper
Property A..B ea,stews t[yand
coifessi ng Cod:)mail connotations -
comwmieesnot(Sec.toaC,werof andrty who Wilds
or Code:)TacCs therem'snd
cense law doe not apply a an owner of property who Wilds or improve Comehi and
who.Lace for such projects with a conuxmr(s)lianxd pursuant a the Canuacm(s
Lkersa Law.
❑Lem eacmpt under Sec. ,BR PC for its moon
Data oC��
WO0.KER5 COMPENSATION DECLARATION O�
1 hereby aRnn under penalty of perjury once of We following declaration:
❑I have and will maintain aCereifiemo of Consent m self-inure for Worknescompcn-
sation,As provided fm by Section 3100 of the labor Code.for the performance of tbe
work for which this permit is issued.
have and will maintain Workers Compensation Insurance,u required by Soedon
3 otic Labor Code,for is performance ofthe work for which this Permit is issued
My Wor Co n dhj j°�''AA�Y+a^^V�'carrier and Policy number'sari'1
Carrier. G ahw1'1^ Policy Nr _'%(4�67—
�...�raB71FICATE OF EXEMPTION FROM WORKERS'
FF COMPENSATION INSURANCE
(This action need not W completed if the Permit is form=hundred dollars(SIM)
or leu)
1 certify that in the performance of the work for which this Permit is issued,l shall not
employ any person in any manner.w As re become bjai i We Workeri Compmedre
Laws of California.Dam
APPlicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject m the Worker's Compensation provisions of be labra Crile,you most
.JO foMwii comply with such Provisions its permit shall be dccmed revoked. +
z CONSTRUCTION LENDING AGENCY
[— 4 IWreby notion that Were,is amnnmcsinn Imiingagency for the perrumn.of
C > the work fur which thin permit is issued(Sec.3097,Civ.C.)
Q Lendeea Name
z landees Address
U C) 1 certify,that I have read this application and shot Wet the above information is
IL Pcenter,I agree in comply with all city and county ondircrues and sum laws relating to
QU building construction,and hereby audorim rep,emnutives of this city to cnmr upon tW
shove-mentioned prep ha for inspection purposes.
F C (We):gra to taw,indemnify and kap harolen the City of Cupertino against
h Iiabilitini.c.c mcnho ndin ofdovnwhich may in any way snout againt mid City
Uz Aconsequence of DERSTAN of this Permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 2_2(-O 4--
Signature
Signature of APPhcuuContracir Dam Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will We applicant or future building occupantsome or handle havardous mamrial
u defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
.ser:denus3z(a)t
❑Yes on All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wildingoecupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hayardnus air contaminants As dcbned by de Bay Ama Air Quality Management all new materials for inspection.
District?
❑Yes 164.
I have mad the ho>arWms innion4is revircments under Chapter 6.95oftheCalifor-
n;allealthASafmyco ,Section 2550, 5 Sand 25534.1 understand dcA it de Wilding
dors n rnt hoes a sun k Naz it responsibility m notify the oecup t or the
requi styli m tbe Ipooru nu ec of a Cerdricate of panq�
t %Ll Signature of Applicant Date
Owoere,Wtho udag in ❑„e All roof coverings to be Class"B”or better