03120010 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CQNTRAGTUR IN `CATIf3N•.
BUILDING ADDRESS: PERMIT NO.
RUDOLPH & SLETTEN INC 03120010 '
OWNER'S NAME: - PERMIT ISSUE DATE
NE: SANITARY OL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 LICENSED CONTRACTOR'S DECLARATION - - - — ' - Ib Description
ss 1 hcmby aMan NOI
at 1 am licensed under provisions of Chapter 9(commencing p
< ith Section 7").f Division 3 close Burin d Profeasimu Cadia.md my license is
bM d IR�o�
z�z
in 111° DH a DEFERRED SUBMITTAL-STRUCTURAL
° °eARCHITECTSD ser AT ON CURTAIN WALL-M/E SUPPORT
� Im
{�ralandmyplansahallMusedaa mmenrm ORIG PERMIT 02080131-IN HOUSE ONLY
° u
3 C Licensed Profusaional
OWNER-BUILDER DECLARATION
I hereby affirm on I am exempt from the Comracmrs License Lew for me
O O following reason.(Section]1131.5,Business and Pra(a moll Code:Any city st county
$ which require m Permit set oust the
alms,improve,h Permit a lir repair any structure
pdonoiucensed u.dsontto the meapplicant
soffor such Permit Lecturfile asigned sutcmcm
F e
that sedpuewion700epreviameafmCG00memriLJeenseTaw(Chapter
ram)a, Sq.Ft.Floor Area Valuation
es $
(commanding it Section and of badsofrnftWegedessantl ProtesyACodc)or
Nat he in exempt dmmfrom and Ou baso far the alleged exemption.My violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom Nan Eva hundred dollars($500).
❑I,as owner of Ne pmpeny,a my employee with wages a a their sole compensation,
willdo the wmk.and meswcmre ismaimended oro@red portals(See.7046.Business 31607046 . 00 Required Inspections
and Professions Code:The Conbectara Liana Law does not apply m an owner of q P
propertywW Wildsmimprove thereon,endwho doessuch work himselformeaugh his
own employca.provided thstauch improvements ase nmmmnde I oro@red tarsale.If,
however,on,building or improvement is sold within arc year of completion.Ne awrcr-
builder will have the burden of proving that he did not build or Improve far purpose of
sam).
❑I,a owner of me property,am exclusively contracting with licensed contractors to
contract the project(Sec.7044,Business and Professions Code:)The Conmtes's U.
came law does not apply in an owner of property who Wilds or improves thereon,and
who caobuce,for such pmjecu with aconncmr(a)licensed pursuant to the Contractors
License Law. (�
❑1 not eaempl under Seo. ,B&P C for this mean S
Owner Data
WORKER'S COMPENSATION DECLARATION ]
1 hereby affirm under penalty of peejury arc o(the following declarations: ✓\ -
T haw d anwid amar uin aCenlOcau o(Canunl m.II-m,ma f.Wmlmes Campem V
nation.as provided for by Section 3700 of the labor Code,far the pi rfa manor of the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,a required by Section
37M of the Labor Code,for the performance of the work for which this permit is issued.
My Work/ees Compensation Insumnce cani�cdrr�annd�d Potlyicy number are:
er.FillsOETIFIC 1 �FoRcyFtyo.: WORKERS' CX,,
t0'i
CERTIFICATE OF E ATIO ON RA
COMPENSATION INSURANCE
(ITb section need not W completed if the Permit is parade hundred dollar($100)
or las.)
I certify that in me performance of the work for which this Permit b issued,I shall not
employ any parson In any manncrao in be become subject to me Worker'L'ompensation
Lawn of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become Subject to the Worker's Compensation provisions of me Labor Code,you must
Q 2 formwim comply with such provisions or this Permit shall W dcemud mwked.
ZO CONSTRUCTION LENDING AGENCY
Fa Ihereby affirm that them N a combustion lending agency for the Performance of
C a7 the work for which this Permit is issued(Sec.3097,Civ.C.)
V.1 Q Landers Name
.7 z Landers Address
U Q I certify that I have seed thin application am sum that the aWw infomn n on is
1,, F Cm=L I agree to comply with all city and county ordinances and sub laws relating to
0 abow-gcoewctiroend hereby mmonmrepmsenutiwa of Niaciryto color upon dm /
W ahovc(We)amod greproperty for impaction
mnify anpurposes. r/L�y/G//�/r
fY
(We)agmen to ave,indemnify and hep harmless the City ro against
id against
a„a y liebilitleajudgmenu,caeca and expenses which they in any way ceases against aid City
U Z in consequence of me gaming of this permit.
ar APPLICANT U DERSTA AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCER TI S, �/�
�104 -19ID ' Re-roofs
Sgnat of pman ontraccar m
HAZARDOUS MATE LS DISCLOSURE Type of Roof
Will We applicant or future building occupant stare or handle hava dour material
as defined by t th Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Sectio.2553](a)? \\ All roofs shall be inspected prior to any roofing material being installed.
❑Ye fYNu
applicant or
Will the appnfuture building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit Immumus air conuminamu as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes Nu
1 have read me haemnus materials requiremumu under Chapmr G95 of me Califor-
niaHcalth&SafmyCodc,Sec ms;25505.25533 and 25534.1 undcrundthstifthe Wilding
doesnot cu my hew mnan4 met it is my msponsibility to notify mu oecupmt of the
re ne an whi a' met ' hxuamaeafaccmrc ancy.wu,.I Signature of Applicant Date
or m sat arind.golit All roof coverings to be Class "B"or better