03010049 F
ITY OF CUPERTINOBUILDING DIVISION PERMITILDING ADDRESS: RUDOLPH & SLETTEN INC PERMIT NO.
19111 PRUNERIDGE AVENUE 03010049
NER'S NAME: 989 E HILLSDALE BLV - L'ERMITIBRDAT6
HEWLETT PACKARD 02/20/2003
NE: (415) 572-1919 SANITARY NO. CONTROL NO.
ARCHITEC tENGINEER: BUILDING PERMITINFO .
PLUMB
t� l�
3000 LICENSED CONTRACTOR'S DECLARATION Job DLI00
1 hereby alron that I uODSCTIP
n licensee under provisions of Chariot 9(commencing
with Seedon 700)of Dividan 3 of dw Business and Professions Code.and my license Is
o Licmtt
otenCeReck REVISION (PIERS) --IN HOUSE USE ONLY
j se z licenClsss Lu.N
�^ Dau ContractorNO NEW PERMIT ISSUED, ORIG. 402080131
DEC -
ARCHITECTS DECLARATION
I undeownd my phos shall he used as Puhlle records
ysup Licensed Pmfccuanal
5 OWNER-BUILDER DECLARATION
E I hemhy affirm Net I am exempt from ftCommute"Ucease law for Ile -
c 0 o <10
Mww,ing rtemn.(Sa0an 7031.5,Busloess m l Professor.Code:Any city o cci S
$ which rcquima a Permit to construes slur,hnprow,demolish,Car repair any stmeture
pint Initsfamence,aim requires Mappk=l fomch permit to file I lits Nwment
Illelhelelimnwdpmmmlla NepmHYONefft CanlrKwr u...La.whopMr9 Sq.Ft.Floor Area tion
W 3 (Commencing with section 701 of Division3 of the Budneasnd Prolesswi ce $14990000
BB
that he is emmpt 0eteftom and the bark,for Ne dlcgrA ewnptlon.Any virdmim of
Section 7031.5 by any applicant for a permit subjects the applicant o a Civil penally of APN Number Occupancy e
not mom tun fin hundred dollars(M), 31607046 . 00 p yTyP
❑Las vxmrafte property,or myemployces with wages ar then mu compewllon.
will do we work,and thestsoci is not handed cronered for sale(Sec.7W.Bal.
and Proresdam Code:The Cmmractors Lt..Law does not apply to an Or of 101 - FOUNDAPf46%d Inspections
property who builds or Improves thereon,and who does such work him set f or 0uough his
own employees.provided that such imprommmu are not intended or offeree for tela 1f. - 102 - PIERS
however,the building or Improvement is mid within aro Sear of completion.the ownn- 103 — UFER
builder will hero the burden of Moving that W did not Mid or Impmw for purpose of
ale.). 104 - REBAR
❑1.asmet of the property,am emlusiwly Conaanting with licensed Convectors to 105 - ANCHOR BOLTS
Construct the project(Sec.7044,Business and Profession,Cade:)The Contractors U.
come Law does not apply to an owner of property who Wads or improv,themon,and, 106 - SEWER & WATER
who mmnm M such projects with a contractor(a)licensed forward to the Contractor, 202 - UNDERFLOOR PLUMBING '
License Law.
D lannexemptunder Sea ,B&PCforlhisrtaron 203 - UNDERFLOOR MECHANICAL
Owner Dau 204 - UNDERFLOOR FRAME -
WORKERSCOMPENSATIONDF.CLARATION 205 — UNDERFLOOR INSULATION
I hereby effort under Malty of perjury am of the fallowing dcclesumns: 301 - ROUGH PLUMBING -
IhowendwillmaintainaCertaamofconsenuoself-Mum far Water's compen- - 3OZ — TUB & OR -SHOWER
u0on,ns provided for by Section 370 of the Labor Cade,for the performance of the .
akforwMehthisPermitisIssued. 303 - ROUGH MECHANICAL
❑1 hew end will malmaw worker',Compensation Insurance,as required by section 304 - ROUGH ELECTRICAL - -
770af the Labor Code,for the performance of Ne wok for which this pmol is Issued.
My
m
Workers Copenselloe Insurance Cartier and Policy number m 305 — FRAME .
C PolicyNo.: 306 - HOLDOWNS
CERTIFICOMPENSATION INS RA NCFROM E 307
307 — INSULATION -
cmutiniannecdnalnoCompleted inhePermit lafmonchandreddullam($10(1) 3,08 r SHEETROCK
art tea}) - - 309 �,.- EXTERIOR-LATH -
I certify that In the performance of the work for which this permit I,Issued,I shall not 31 O - INTERIOR LATH '
employ any person In any mmi as to become subject to the Worker'Compensation
Laws of California.Dow 311 - SCRATCHCOAT
Applicant I
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should 313 — ROOF NA I L L -become subject In the Worker's Compensation provisions,of the Labor Code,you most SO1 — FINAL ELECTRICAL ENERGY
.J z for ith comply with such provisions or 01,permit shell N deemed mvoked.
'zO CONSTRUCfIONLENDIN0A0ENCY - 502 FINAL PLUMBING ENERGY
[-tom IherebysalonthatthenIsaConswctionlendingagencyl'ortheperformanceof 503. — FINAL MECHANICAL ENERGY "
a�
the work for which this Permit k,Issued(Sec.3W7,Civ.C.) 504 FINAL BUILDING ENERGY
Ipg M Lender',Name
7z Lender'aAddoas 505 - FINAL ELECTRICAL ,
U O 1 certify that 1 hew reed this application and slow that the&bow information Is 506 - GAS TEST
U.0UcoldingCgrtemcomply dwRh all city and county ordinances and taws refining0. '7 - FINAL PLUMBING
U. building contwction,and hereby suthmlse rtpresenloiMaof this shy in enter upon the
W ahovc-mentioned properly for Inspec on purposes O "I
MRCT4A TCAL
(We)agree to taw,indemnify and keep harmless the City of Cupertino against
y Ilabili0es,judgments,costs and expenses which may In any way acme against said City I
U,Z in con"twunce of the Standing of this permit.
vat APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: 5 NG Date
SOURCE REGULATIONS.
Re-roofs
Signature of Applianl/Commclor - Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant Now or handle hats dow material
as Corned by the Cupertino Municipal Code,Chapter 9.11.and the Health and Safety
❑,sectiYeons 15531(4
)7 (]No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use cquipment or R hdcvicca which If a roof is installed without first obtaining an inspection,I agree to remove
vaNnus air Contaminants ar dcfioed by Ne Bay Amt,Air Quality Ment,gemenl all new materials for inspection.
District?
0y C]No
I have rtW the hvaNnts mawdek,requirements under Chapter 6.95 of the Califor•
nu Health&Safety Cade.Sections 13505.25533 t,nd 25531.1 undemand tau lithe holding
does out currently haw a want.out it Is my neweamin,b mdfy the.4.1 of the
mqummentc which most be met prior tohausec orfs Certilkate ofoccupancy.
Signature of Applicant Date
Owner or umorbcel agent Dow All roof coverings to be Class"B"or better