06050065 CITY OF CUPERTINO
BUILDING DIVISION - PERMITzw
�ONTRAGTOR INFQRMATION'"
BUILDING ADDRESS: RUDOLPH & SLETTEN INC P'Bm rN0.06050065
y9091 PRUNERIDGE AVE
S NAME: PERMIT ISSUE DATE
HEWLETT-PACKARD 1600 SEAPORT 'ALVD. STE 3S Q6/01 /2006
PHONE: - SANITARY NO. CONTROL NO.
(650) 216-3643
ARCHRECr NGINEER: BUILDING PERMITINFO
BLDG ELECTPLUMB MECH
0 0 0 0
o o LICENSED CONTRACTOR'S DECLARATION
v 1 hereby alien that 1 am II=v uM r pmvWov of Chapscr 9(commencing Job Description
Z� v,th$ecth, 7")of Division 3 ofthe Business and Prefessiom Code.and my license is
�„ in full force andefreeL jggp�l REVISION TO ORIGINAL PERMIT# 05110136
,�J? Liceva,C a Lic.x
;re Dau: b-1-2-00h comraewr rzQ�LFtl s REVISE BEAM FOR CASEWORK SUPPORT
ARCHITECTS DECLARATION NO INSPECTIONS ON THIS PERMIT
i W U 1 mdasand my Plans shallx
W used as public rords
g,
G� Licensed Professional
OWNER-BUILDER DECLARATION
F I hereby affirm Nal 1 am exempt Item the CormactWs License Law for the
:p c following reason.(Section 7031.5,Business and Professions Code:Any city or County
-m which rtyuires a permit to wnsnuct.dter,lmprovc,dcmoluh,err repair any mocmre
.¢i prior at its Issuance.aim requires the applicant for such permitao file a signed statement
< that he is licensed pursuammdue provisions ofthe ContracmrilucveLaw(Chapter 9 Sq.Ft. Floor Area Valuation
`
~$ (commencing with Section 7000)of Division 3 or On Business and Professions Coce)or $0
-- that he u exempt therefrom and the basis for the alkged exempdon.Any violation of
Section 7031.5 by my applicant for a permit subjects the applicant On a civil penalty of ane APN Number Occupancy Type
,cot mote than five hundred dollars($5070. P Y YP
❑I,ss he.,of the pesurna m my employee Orth wage v the'v sok compensation,
will ck,Pr the wmk,and Ne shucmrt Case,kLMed er Law
dor .1 a(STs.7014,Business
aro property who code:The conhacmrs ndwho law aces ore apply lf rt mune er Required Inspections
own enywho s,pmvi&d tat
suNcrewho docssOchwork honfir ed for Weugh h,
awnemployers,provided Nat such improvementsIsColdartmyear fC Oco@rtE for sneer, -
Auilder.Ne buildingorimprovementusold within ane ildorcompletion.Neowner-
builder will have Nm burden of proving that W did not Wild Or improve for purpose of
solo.).
0 1,as owner of the propeny,am eachnively contracting wit licensed Conhacrors b
covtmet the,project(Sec.7(tad.Business am Professims Cade:)The Coa emr's U. .
cove Law d.not apply to an.of property who Wilds or imp.es tW ream,and.
who comncu for such pmjem with a conuanor(s)Iiansed pursuant to the Contactors
License law.
❑I am nacmpt under See ,B&PC for this maven
Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declare me;
0 I have and wall maintain a Cer ifi.m of Consem to self-insure for WmkersCompm-
sation.as provided for by Section 3700 of use Labor Code,for the Performance of the
work for which this pewit is issued.
0 1 have and will maintain Workers Comprnsation Insurance,as requited by Section
3700 ofthe labor Code,for On per(ormanCo ofthe work for which NU permit u issued. '
My Workers Compevation hsurance carria and Policy number H:
Grie, AmL-etcAN Policy No.:,5'4"1D6
CERTIFICATE OF E)(EMP ION FROM WORKERS'
COMPENSATIONINSURANCE
Thu section need Mt W completed if[be pctmit is For ane hundred dollars IS 100)
less)
1.10 fy Nat in the puf...of the work for which CO.permit is Issued.I shall net
employ any Penin in any toasmr to as at become subject to On WorkerCompevatioo
Laws;of Califomia.Date
Applicant
NOTICE TO APPLICANT:If,arm,making this;Cenifa¢of Exemption,you should
become subject m the workers eompcnsadan provisions of she La Wr Code,you mus
.J O foMwuh comply wit such provisions or this Pamir that bo deemed revoked.
zN CONSTRUCTION LENDING AGENCY
[—, Iherebyal0nn that Ncreiso construction lendingagcnry in,the famim once of
a the work fur which NIS permit b issued(Sec.3097,Cie C.)
W�~n- Landers Name
z Lenders Add.
U C) 1 certify this I have road Nis application and sure OR the above information is -
Ur F" tonna I agree p comply wit all city and cowry on itarees and state laws relating to
DU Wilding construction.and hereby authodm tepmaedutives of this city to enter upon the
W
move-mcduored property for inspection purposes.
C (We)agree to save,indemnify and keep handless On City of Cupcnido against
Iiabilities.judgments.Boss and expenses which may in any way accrue against said City
UZ in consequence of the granting of this Permit.
�—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date i �6
SO EREGULAMO�aNS�, n _
Re-roofs
Signature efA IipHh ARxms
r pa
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the n Cuptent w future bottling e.Chaptnae wand the
hauNons mapnal
Brod O Ne Cupertino Municipal Code.Chapter 9.13,and IW HeaIN and Safety
.ScNen zss3z(a)7 / All roofs shall be inspected prior to any roofing material being installed.
❑Ya pl Nu
Will the applicator future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haramous air contaminants an defined by lie Bay Area Air Quality Management all new materials for inspection.
District
E]yes )2rN.
I bare read the Weandas ntatenab mquirements un@rCWpter6.95efNe Califm-
rusHealth&SafetyCOdc.Sa7ios 25505,25533 and 25534.I urhsand ths if the Wilding
does rpt mOcruly,have a ten.L Nu It u my tespovibility a,rptiry,On occupant of dp
regyrmc(Y(tMnuwhich..Wmelp.C,lon enceof.certi0cateorOe Signature of Applicant Date
l 6=�-06
O ger or su horiud agent DateAll roof coverings to be Class rB"or better