03020080 CITY OFCUPERTINO
BUILDING DIVISION PERMIT CONTRACrORhINFORMATION
BUILDING ADDRESS: RUDOLPH & SLETTEN INC PERMITNO.03020080
NEWS NAME: 989 E HILLSDALE BLV PERMIT ISSUE DATE
HE
"E: (415) 572-1919 SANITARY NO. CONTROL N0.
7AR-Elln-CTIENGINIER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
oLICENSED CONTRACTOR'S DECLARATION
I herchy afarre that I am licensed under previsions of Chapter 9(commencing Job Description
ectionndeffecDivision3of the BusinaaenJProfessonsOtic.enmycenses= ull force and effect.,qneoClam Lic.N REVISIONREV
c Dam COntmmm ASE BILLED US $444 . AND THAT WAS PAID 3/19/03
$$rr ARCHITECTS DECLARATION
iN Iand eratandmypi.m,hallWused upibliemcnrds ORIG. #02080131
)iU
'0 Licensed Pmfcssicnel �\
OWNER-BUILDER DECLARATION
0 I hcrcby affirm on 1 1. exempt from the Contractor'sLicense: c Law for the
:00 following moon.(Section 703L5,Business and improve.
dcrinns Code:Any city or aunty C�
1 which requires a permit re cnnswu,aalmlpplicant
i t forsu demolish,or to signed structure v
-Z i• Olor d he iLLiensedp pursalso uant
the
ovisio sof forsuch micensle ae Law(Chapter
< thatheincingudpSectio 7 (1ofDivismofthe oftheStronessandenselaw(ChapmrY Sq. Ft. Floor Area sly3attO❑ -
2 9 (cat he is
(commencing Section 70(1 of Division she
alleged
andon.Any
Code)or
that he is exempt therefrom and Ne basis for the allcgctl exemption.Any vinlalion of 14990000
Section 7031.5 by any applicant for a permit subjects the applicant to a Civil penalty of APN Number Occupancy Type
not more Nan five hundred dollar.(SM. p y yp
❑I,as owner of the property,or my employees with wages as their sale compensation, 3 1607046 . 00
will do the work,and the structure is not intended or offered for sal,(Sec.7044,Business
and Pmfessiana Code:The Canmmun's License Law docs not apply in an owner of Required Inspections
property who Wildsor improves themon.and who doesmch work himuff or through his
Own employees,previded that uch improvements are not Intended or offered formic.If. .
however,On building or improvement Is sold within one year of completion.she owner.
Wilder will have she burden of proving that be did not Wild or improve fm purpose of
saleJ.
1, 'Cow owner of the property,am exclusively contracting with licensed contractors to
on n the prejcct(Sec.7044,Business and Profnssions Care:)The Ontrommr's U.
cense law does nm apply to an owner of property who Wilds or improves the mon.and,
who coanom forsuch projects with a contramorts)licensed pursuant o the Contractor's
License Law.
I am toix un Se /,/y .B&P�C far
�this
�madum
r / - Dem_ItJIJ ALL/_/
W I0 'S lrfB`TSNSATION DEC ATION
(here elBrtn ulidc penalt al perjury one of Ne fallowing decimations: '
10"_,Ly�""orkces
ave and will mainuinaCcnifume of Consent to self-insumfor WorkcriCompen-
,u provided for by Section 37W of the labor Cade,for the performance of the
fm which this permit is issued,
ave and will maintain Workers Compensation Insurance,as required by Sccdun
of the Labor Code,for the performance ofthe work for which this permit is Issued.
Compensation Insurance artier and Policy number am:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This secdnn need not W completed if tbe permit is for one hundred dollars(SIM)
or less.)
1 certify that in the performance of Ne work for which this permit u Issued.I smil not -
employ any person in any mannerso as m become subject o the Workeri Compensation -
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.eAct making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the Labor Codc,you must
7p forthwith comply with such provisions or Nis permit shall be deemed revoked.
ti h CONSTRUCTION LENDING AGENCY
—� I hereby affirm Out more is a construction lending agency l or the performance of
X 7 to..,it fur which this permit is issued(Sec.3097.Ci,C.)
UQ Lender's Name
3 z Lkader's Address
;)0 I certify that 1 have read this application and slate that the mroa information is _
L t"' cartect.1 agree to comply with all city and county oNinamcs and state laws mlating to
V building construction. it ction. hereby amhorim representative of this city m enter upon the
Y C ahovomcminned progeny for inspection purposes.
(We)agree to save,indemnify and keep harri the City of Cupertinoagainst
'Aliabilhiu.judgments.costs and expenses which may in any way accrue agamm said City
in
APPLICAeTeof om DERmnANDStbts ponarit.
ND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEN NS.
O 3 Re-roofs
newre of Applica V ommnor Dam
AZ RDOUS MATERIALS DISCLOSURE Type of Roof
Will thc applicant or forum Wilding acupant Some or handle hanrdous material
as carined by the Cupenion Municipal Code,Chapter 9.12,and the Health and Safety
I
de,Seeuen3ss3z(m �..__,,,//,,//// All roofs shall be inspected prior to any roofing material being installed.
C]Year —
Will to applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haevdaus air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
nlet?
DYca
I have read Ne licand msmaearialsrequimakenu under Chapter 6.95 Close Califor.
Health&SafetyCods,Secdou255a5,25533 and 25534.1 understand tbat Ron,Wilding
cs not to Ay have a¢nam,that it is my responsibility,m notily the acupant of the
uircmcn hih sett tpoor Inissuanic ,ccnifcm Gccu cy. Signature of Applicant Date
11 ` ( �� 03
ner or author' dagcm Datc All roof coverings to be Class"B"or better