06050064 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �OiVTRACTORIAtFNORMATI01V
BUILDING ADDRESS: RUDOLPH & SLETTEN INC P"""NO06050064
19091 PRUNERIDGE AVE
R'S NAME: PERMIT ISSUE DATE
t
HEWLETT-PACKARD 1600 SEAPORT BLVD 06/01/2006
PHONE: - SANITARY NO. CONTROL N0.
(650) 216-3643
ARCHffECT/ENGINEER: BUILDING PERMMNFO
BLDG ELECT PLUMB MECH
loo LICENSED CONTRACTOR'S DECLARATION
u+FF I Iemby affirm that l am licensed under Intimates of Chapter 9(commencing Job Description
:Zya with Section 7000)of Division 3 ofte Business and Profcssiau Cade,and my licensee
<e in full force and affect
=h ORIGINAL PERMIT 06020171
tqz License lass Lt.
•a,'o Dale ^ - eomnnor ZaaootiPH �Ztaa REVISE CASEWORK & FAN COIL UNIT SUPPORTS
ARCHTECrSOECLARATION NO INSPECTIONS ON THIS PERMIT
i I utWcnunJ my plans shall W tied as public records
IdL
Lnmued Pmftssional
3 OWNER-BUILDER mDECLARATION
00 I hemhy alum on 11. aurin from IW ConrastCo Llcenx Law for tW
o O following moon.(Scetion 703 1.5,Badness and Pmfcstiou Code:AnY city or county
j$ which requires a permit to construct.after,impmm.demolish,or repair any structure
.¢iprior at its issuance.also requires the applicant for such perrni Do Bic a signed sutemcnt
that Ito is licensed pursuant to tW provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
1FG (commencing with Smion 7000)of Division 3 ofthu Businessand Profcssimns Code)or O
!92 Nal W u exempt therefrom and the basis for the alleged esemptim.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil imnahy,of APN Number Occupancy
not mart than five hundrtd dollars(5500). P Y Type
❑1.ummrufthepropmty,amyemPloyceswithwagesuJ iridecompenudon,
will do de wort and the sWcture u notintended oroRemd forms,(Sec.7014,Business
and Famfosa mus Code:rbc Communes License taw claws ret apply to am ower of Required Inspections
property who builds car im prow thereon,and who does such work himself ser through his
own employees.pmvided Out improvements me Out intended oro@red formic.IL
however.lie building or improvement is sold within one year of mmpledon.the owner-
builder will have the burden of proving Wt bo did mot build or improve for purpose of
sale.).
❑1,as owner of the Property am exclusively contracting with li arced cavuaaas to
comoui the project(Sec.7064.Business and Professions Cade:)The Conuaco's U.
eve law docs not apply us an owner of property who Wilds or improv daemon,and.
who contracts for such projects with a contractor(a)licensed pursuant to this Calamities
Lkemss Law.
❑1 am esempt under See ,B&P C for this on
Data
WORKERS COMPENSATION DECLAR VIDON
1 hereby,affirm under penalty,of perjury ane of de fallowing declarmions:
❑I h:m and w01 mainuin aCmtifiax of Couentm self-iesum ror WorkelsCompen-
action,as provided for by Section 37M of the labor Code,fm the performance of de
walk for which this Permit is Wood.
❑ 1 have and will mainuin Wmkefs Gmpemaion hwnn¢,as required by Section
17M of the labor Cade,for tike performance of the work for which this permit is issued. '
My Worker's Compensation Inwmtce carrier and Policy no11r �
Gorier.�i41..^!Ln Policy Na.: SS
CERTIFICATE OF EXEMPTION FROM WORK S'
COMPENSATION INSURANCE
(This maim heed Out boconpletid if the permit is foohe hundred dollen(1100)
or lem.)
1¢nify that in the Performance of Be work for which this Permit Is based 1 shall not
employ any person in any manners as ur Wmme subject in the Worked Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:It,after making this Ceniriale of Faem ru.m.you sbmW
become subject to the Wor e s Compcnaauon provisions of the Tabor Code you most
.,O foMwith comply with such provisions
or this Permit shall he deemed revoked.
z CONSTRUMON LENDING AGENCY
[r Ihereby affim that thcrt is a construction lending agency for the perfomnee of
lY. > the.,it for whim this permit is Wood(Sec 3097,Civ.C.)
Gt<ndch Name
r7 z Umulm.Address
U0 I coldly that I have mad this application and some thabou
t the ave information
Is. P^ correct.I agme m comply with all city and county onfin.and mux laws relating to
0U building carotic,ion,and hembyauthoire mpmscmatiw of this city to enter upon the
ahovomcntiuncd nts.c s for capecdnn purposes.
F y (We)agree m sive,indemnify and keep harmlea the City of Cupertino,gains,
h in
oftscmuand ftia Permit. may in any wayaaruc against mid City
Uz in eanxgmncc of the gaming alNis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date � /_ S
�
SOUM REGULATIONS.
" ' AAA_ 6-1-Ob Re-roofs ---��
Sign use of App candConthcmr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
wlitWapplicant ser forum Wilding awmpanutomor handle Heal, anmaterial
Med io the Cupertino Municipal Code.Gaper 9.13,and the Health uJ Safety
Section 15532(a)?
❑Ya ONO All roofs shall be inspected prior to any roofing material being installed.
wit the applicant or fuure building occuln a,me egnipmcn,or de.ims which If a roof is installed without first obtaining an inspection,I agree to remove
emit harudmu it comaminams as delieed by the Bay Area Air Quality Mandgcmcn, all new materials for inspection.
Daniel'
❑Yes ONO
1 haveread theb.r dom5505,s5533mdM .lu Gaper6aofthe Glding
nice Hal Barr fdsy Cve a whimm33t it ii. y oussib34.1 indcrstsnd a occu c Willing
Joes cnas hiy Wo�a Isant me i,u s reapouihiliry,m ae or the Prsupan,o!the
mgoi muwnichmunWmc,prarmiaman er.cen;Ramara Pana. Signature of Applicant Date
_ ✓l/�_/ �l-old
0w rorm nmdagent Dam All roof coverings to be Class "B"or better