04070081 CITY OF CUPERTINO
BUILDING DIVISION PERMIT , CONTRAC'�ORINFCIRMATICIN' -BUILDING ADDRESS: RUDOLPH & SLETTEN INC PERMITNOO 4 O 7 O O S1
19111 PRUNERIDGR AITR 44
OWNER'S NAME: PERMIT BSUB DATE
EOHP
SANITARY NO, CONTROL NO,
(415) 572-1919
ARCHITECTIENGINEER: BUILDING PERM INFO
BLDG ELECT PLUMB MECH
X00 LICENSED CONTRACTOR'S DECLARATION - -
0
i�u I Wn 7 affirm than 1 am rowficanewd under proviuou of Chapter 9(mmmcnse is Job Deseript
H withS carce"IX3)af DiWsion3af dm BusinessaM Profeulum Code.and my license is
nig4 inrunmma. �p(p TI--NEW ICE & SODA FOUNTAIN
p)a? Licenx Cln L..At
Contractor
AR NITECI-S DECLARATION qtb 7Vff JAN W5 ZOOS
? U I undo and my plans atoll W used As public records
BUILDING
ZpG Licensed Professional
L H.1 OWNER-BUILDER DECLARATION
E 0 I hereby.(firm Net 11. "umpe from Ne Canon Cod License Law for Ik
E p O following mann.(Section)1131.5,Business and vet demolish.
e oli Code:Any city or ectomy
which requires a permit ht construct,elmq improve,dcmnll h,Or rtpeir,any nmcmm
fZi prior An its issuance,also nquiws theapplicant for such Permit o file.signedsusmem
O Nat he isliccnscdpursuanttothepmvislonsofdicCommurriLicenseLaw(Chapter9 Sq. Ft. Floor Area Valuation
$ (commencing with Section 70M)of Division 3 of NC Basinesa.nd Professions Code)or
thus k s esempt thertfmm and the hula for the Alleged cremation.Any violnlon of
Section 7031.5 by any appli"m for a permit Nations the applicant to a civil Penally or Type
not mom on Ove hundred dollar($500). er0 O Occupancye
❑L ot owner of the pmpm e m my employees with wage u they sale e0mpenution,
will d0NewotW ands: h.Cont.nor',Liens LAWddforssla(Sec.7044,Business
and anywh obu Code:The Comncmn,License Law dose oat apply to an owner is Required Inspections
property who builds or improves Herron,end who does such work himself or through his
mvncmployces,provided thmsuch i ais sold it are not intended or ho...Russia r.
however.Ne Wilding or improvemenn is sold within one yeti of completion,the awur-
builder will have the burden of proving Net he did not Wit or Improve(m puryme of
tile.).
❑1,re owner of the property,am"elusively contracting with licensed contractors in
construct Ne project(Sec.7044,Busineu entl Professions Cade:)The Correctors W-
cense Law docs not apply to an owner of propeny who Wilds or improves thereon,and
who summers for such projects with a canusetar(,)licensed pursuant an did Comncm/s
License I. w.
❑lernexemptundm Sec. ,B&PCfarthisreason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under pedaily Of perjury ane of it following docWtimo:
neveend will maimein a ConiO"se of Canaem to self-inure far WarkeraCampen-
uon,As provided for by Section 3700 of the labor Code,for the performance of the
.it for which this permit is isumd.
32 onto And will maintain Worker's COmProaalldn Insurance,As required by Section
of the labor Code,for the performance ofthe work for which this Permit is lsaued.
My Warkepr,.,-Com vegan Inwnnce es and Policy n onoer art:
Cartier.^,'. L' co-
911?ditty No.: gvGta9S3C7 Q
CERTIFICATE OF EXEMPTION FROM WORKERS' I '
COMPENSATION INSURANCE
phis section need not kcompleted If the Permit is for one hundred dollars(3100)
or less.)
I cattily that in Ne performance of tho work par which this Permit is issued.I shall not
employ any person in any manner an as to become subject to the Worlicrs'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of fie Labor Code,you must
.,,'Z foMwah comply with such Previsions or NS Permit shall k gamed revoked.
z O CONSTRUCTION LENDING AGENCY _
(-+ 1 hereby aRbm that Nem is a conswctinn lending agency I'or the Performance of
!Yi the work for which oaa pemtitjs tied(Sec.7097.Civ/.�CJ
=z Lender
Lender's Name
[
's Address
U Q 1 certify that I have mad this applic.w.and suite on.the akve information s
lL H correct 1 All an comply with all city and county ordinances and Suss laws mining to
0 building convection,and hereby authorirc minceemalirxs of this city to enter upon the
for
W akveiiajudnodpmPeny andexecaus which
may
a tWo)agree Ice save.indemnify And keep humless he City of Cupenina against
r-t fA Ifidaiiin
ts.on coca ingwfuhia ee Tit. may in any way.cone against said City
A ca"C NT
of Ne granting of this Permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Stgumrt ar AppbranUConuscmr Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tha applicant or futon building Occupant store or handle hanrdous ma¢rial
As defined by dm Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
Code.senna zss3z(.n All roofs shall be inspected,prior to any roofing material being installed.
Yu �TTo
r If a roof is installed without first obtaining an inspection,I agree to remove
Will IW air c n to m future building occupant use equipment rk devices which g p
hovardou air contaminants u dcfncd by the Be,Arca Air Quality Management all new materials for inspection.
ruictT
❑Yes WNu
1 have mad the buardous mxmrialsmquiremens under Chapmr 6.95 of the Califor.
nia Health&Safety Coda,Secfinn 25505,25533 and 25534.1 undersand Nat ifthc Wilding
docs IgI tonically have a..L WI it s my wwAwihility to notify IW axupam of tho
milane IT =Wmupriormiss"nccaf.C.Iifmateofcuprawy Signature of Applicant Date
Owner ar aunhorircd sgeml5ine All roof coverings to be Class "B"or better