02080131 CITY OF CUPERTINO
BUILDING DIVISION PERM C4 NTRACTOR;INFURMA*1N."'.
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Bu1LDINGADDRESS: RUDOLPH & SLETTEN INC PERMITNO.
19111 PRUNERIDGE AVENUE 02080131
NER'S NAME: 989 E HILLSDALE BLV APPLICATION SUB DATE
HEWLETT PACKARD 08/22/2002
NONE: (415) 572-1919 SANITARY NO. CONTROL NO.
ARCHITELTIENGINEER: BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
00 LICENSED CONTRACTOR'S DECLARATION
of Char
1 Hereby arum mm I am Becnace anecr provtdnna of cnalmr v fcnmmcncing Job Description
2y, with Scutiun]Ikkpof Division3nl NC Ousm sane Pmfesainns Cnde,andmylleensls ®
zOq� '" `�A 19Ao6 BLDG 44/VOLUNTARY SEIS
z ucenae cl as 9 IOC
Fye, j Dam T'S' LO RKTIO)nf-0la AND SI M7; ,
mm4� r As shall
RECD ATION
to C a 1 understand my plans sM1all M used as public records CT
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Li
LLp� OWNER-BUILDER DECLARATION
vi
I hereby affirm that I am exempt from the Contractor's License Law for the
ii O C following reason.(Section 7031.5,Business and Professions Code:Any city or county
Q which requires a permit u+construct,alcor,improve,demolish,err repair any structure
prior to Its Iss rune.also roidnioN me applieard Ior such Permit o rie a signed statement
pts'< that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 Sq. Ft.Floor Area 14990gdltth[ion
Fd.0 (commencing with Section 70,10)or Division 3 of the Business and Professing Code)or
y Nat he is exempt therefrom and the basis for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars($500). -3-LAPNf4MbePU Occupancy Type
❑I,azowner of the properly,or my cmployccs with wasesuNeir sole compensation,
will do Ne work,and the structure is not intended oroffered for sale(See.7Md,Business
and Professions Code:The Contractor's License Law does not apply to an owner of 102 - PIERS egmred Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements we not intended oroffcred formle.IL 103 — UFER
however,Ne building or improvement is sold within one year of completion,Ne owner.
builder will have the burden of proving that he did not build or improve for purpose of 104 - REBAR
rale) 105 - ANCHOR BOLTS
D1,as owner of the propcny,am exclusively contracting with licensed contractors to 106 - SEWER & WATER
construct the project(Sec WW,Business and Professions Code:)The Contractor's Li-
censo Law does not apply to an owner of Property who Wilds or improves thereson,and 202 - UNDERFLOOR PLUMBING
who contracts for such projects with a contretemps)licensed pursuant m the Contmcmr's
License taw. 203 - UNDERFLOOR MECHANICAL
D l am exempt under See. ,B&PC for this mason 204 - UNDERFLOOR FRAME
her Dam 205 - UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION 301 - ROUGH PLUMBING
I hereby aRtm under penally of perjury one of the following declarations: 302 — TUB & OR SHOWER
❑Ihave and avm maintainbScou NBcamafConsent l.als Cams suremr Workers Compen-e.fthe 303 — ROUGH MECHANICAL
rasion,as province for ray ScNnn raw of the tactor Cude,forflue performenro of Inc
work for which thispermtisissued. 304 - ROUGH ELECTRICAL
D 1 have and will maintain Worker's Compensation Insurance,as required by Section 3 O 5 — FRAME
37N)of the Latin,Code,for the peKotmance of Ne work for which this permit is issued.
My Worker's Compensation Insurance eerier and Policy n k"'o: 306 — HOLDOWNS
catn�A)_A9 ILA4 'Zu21GB Policy N7w we3al�s l- 0 307 - INSULATION
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 308 - SHEETROCK
(Thisscctlon need not W completed ifthe permitirrnrone hundreddollars(SRMB 309 - EXTERIOR LATH
mkis`) 310 - INTERIOR LATH
I certify that in the performance of the work far which this permit is iswcd,l shall not 311 - SCRATCH COAT
employ any person in any manner so as to become subject In Ne Workers'Compensation
Laws ifCalifumia.Dam 313 - ROOF NAIL
Applicant
NOTICE TO APPLICANT:IG after making this Cenilicate or Exemption,you should 501 - FINAL ELECTRICAL ENERGY
Weome subject to the Worker's Compensation provisionsofthe Lahr Cnde,you must 502 - FINAL PLUMBING ENERGY
O Z forthwith comply with such provlsionsor this permit shall he deemed revoked.
z 0
CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
ad N: k far which
thmn itthem is ssued(Sued 097.Cmgagency lmthe performance of 504 - FINAL BUILDING ENERGY
a � the workfnrwhichthis pemitisissucd(Scc.31 ],CivC) 505 - FINAL ELECTRICAL
W Q Lender's Name
z Lender's Address 506 - GAS TEST
U p 1 cerify Nat 1 have read this application and sum thamhe above information is 507 - FINAL PLUMBING
W P corner.l agree to comply with all city and county ordinances and.state laws relating to
Q U buildingcommuchomandherebyauthrrimrcpresereivesofthiscitytocnmrupon he 5 FINAL MECHANICAL
W above property for inspection purposes. 09 — FIN
ty s j.agree to save,indemnify and keep may
in b lM City of Cupertino against
y ADE 11
liabiliti(We)grentosaw,indexpenses nifyand which harmless
humCy way accmeahourril pertinsaid city 5 N G
U z in consequence of the graining oft is permit.
F-t APP ICANT UNDERSTAND ND WILL COMPLY WITH ALL NON-POINT Issued by51 WORKS Dat
ERE UL IONS.
tb DZ Re-roofs
Si tumofAp icamlContracler Dam
IiAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant err fumrc It )dins ipantsmre mhor chaeare^usmaterial
as defined by he Colorado MmZeipa c. hapmr 9.12,ane the Health and Safety
ode,Section]5532mr? All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will thea applicant or finurc buildi If a roof is installed without first obtainingan inspection,I agree to remove
pp ng t ant uu cyvipmem or devices which P g
mit baramous air contaminates as dein y the Bay Arca Air Quality Management all new materials for inspection.
District?
Dyes D
I have mad the haaar usmamrial myuimmenuunder Chapmr6.95uftheCalifm-
niallca1N&Saricty Code,Smtions255O5,25533md25534.1undcmtmtdthatifthc building
does not currently have a tenant,Nat l TImy resia+mihility to nndfy the ne"Pnt of Nc
t
raw wh omoat met pmt suanccuracenifica I parry
(6o Signature of Applicant Date
neraraulhmn cd gem Da,e All roof coverings to be Class "B"or better