06050126 CITY OF CUPERTINO ; w ' ^' "'
BUILDING DIVISION PERMITCONTR.i�G,Ty(iR INFORMATION
BUILDING ADDRESS: RUDOLPH & SLETTEN INC PERMIT No.06050126
19111 PRUNERIDGE AV
E0.'S NAME: PERMIT ISSUE DATE
HEWLETT-PACKARD COMPANY 1600 SEAPORT
FRONE:
SANITARY NO. CONTROL N0.
(650) 216-3643
ARCHITECVENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�Op LICENSED CONTRACTOR'S DECLARATION Job Description
e w I hereby affirm that 1 am licensed under previsions of Chapmf 9(commencing
^<, witScction]Or*)of Division Jofda Bumness aM Prof 'v/C�ode.W mylicenx is
O in full force and effect. 151 �CJ COMMERCIAL NEW 27111. AND REMODEL 68 , 115 -
#z Licen Cl Lie.x
q Dao: Canrazwrej
^ W ARCHITECTS 1ECRATION OVER-RIDE OF VALUATION PER GREG C.
m< I understand my plans shall he used as public records
DyU
got; LwInced Professional
S OWNER-BUILDER DECLARATION
F I hereby affirm Nat I am exempt from tc Contractor's License Law for to
O O following reason.(Section 1031.5,Business and Pmfecsimu Code:Any city or coumy
K m which requires a Permit m eonstmat aloe,hnpmve.demolish,ear repair,any,auudure
Prior to its issuance.also require the applicant for such permit to Rk a signed sutemem
x
that he is licensed pursuant o the provisions of the Contmctur's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
yt—$ (commencing with Section]0007 of Divisionlmf dte Business Professions Codc)w $7000000
f 5— Nat he u exempt therefrom and the basis far due alleged esadpewv Any violation of Y
Section 7031.3 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom Nan five hundred dollars(5300).
0 I,as owner of to property.or my employers with wage as te'u tele Compensation,
will de dte work,and the structure is notimended err aRered forage(Sec.]ON,Business
and Preferments Code:The Commander Limme Law dao tot appy m an owner of Required Inspections
Property who builds or improves Nemon,and who docssuchwark himself ortmugh his
awn employees,provided that such improvements are not intended ordRered for,ule.If.
however.the building ar improvement is sold within erre year of eempleeen,dte owner-
builder will have to burden of proving that he did tot build or improve far purpose of
oda).
i1
❑Las owrcr aj the property,.B exclusively wntuctiqounds with:)The
nsumes Li-
Law
construct the project(Sec.]014,Business and rty whoons Code:)The es thacmr's n
cense eves nes aDPIY b an dwna of property who builds or improves tkmon,and.
who comncts far such Mejects with amnuaxr(s)lianxd Pursuant x the Conuxwh
Lkenx Law. 0❑lam exempt under Sm .BBPCfor Nu reason
r Dam
WORKER'S COMPENSATION DECLARATION
1 hcmby a i m ender penalty of perjury one of die following trclaaiam
0 1 haveand will mainui^a Cenlfiareof Covent m ealr-ircurefor Wanker'a Compe^-
.our.n provided for by Section 3700 of the Lahw Code,for the performance of the
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Secede
3]000(dte labor Cade.(a,to pedrumanee of the work fwwhich this permit is latwtl. '
My Werke/C/'s,C,.omprmation lose carrierand Policy number art: �I
Cartier.JT"`CY'�// ULvn Policy No.: � y 9S^f/�f�3
`
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ITuseainn need notbecompleted if the Permit u foredo hundred dollars(SIM)
or less.)
I Certify that in the perfe marce of the work for which this Permit is issued.I shall not
employ any person in any mannsrx A no became subject in the Workers Compcnaank m
Law s of CaRfomia.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Ccnificmc of EscmPtion,you should
became$object m the Workers Compcvaddn provisions of the Isom Cod,you mass
.J O fuMwith comply wit such provisions,or his Permit shall W deemed mvked.
z""' CONSTRUCTION LENDING AGENCY
'rt wow Thereby affirm that tem u a cawroaiom kndingagemy,for she perform an ca of
ai > the work for which this .it is issued(Sec.3097,Civ.C.)
WM Q Lendcr's Name
.7 z lender's Address
U C) I Cenify but 1 have head this application and sum that tc above information Is
Is.f-' cnnecL I qme to Comply with all city and county ordinance and sum laws misting to
0U building Convection,and hereby authorae mprescrooms or this city to enter upon tc
r W ahovc-mcmioncdpropony(and cxitema purposes.
Egy (We)agree to save,indemnify and keep bamdess be City or Cupertino against
'fg Iiabilitie,judc of thecdstsavdof this emit. may in anyway accrvo against said City
U z nxquenee of the granting SNis permit.
I
A oLICA UNDER ANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO ,4 EDU S. i /O�
[� Re-roofs
Sigvmhe of A,lia^VCdnu teac, Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the appliem w future Wilding daupantmom o handle hazy dons ma erial
As declined by the Cupertino Municipal Code,Chapter 9.11,and the Health and Safety
.Section 255320)?
0Te All roofs shall be inspected prior to any roofing material being installed.
V.
,` If a roof is installed without first obtainingan inspection,I agree to remove
Will the applicant in furore building occupant tau a Air Qu w device which P g
emitict? v air cwmmirunts u dcOvd by the Bay Ana Air Quality Management all new materials for inspection.
District?
Pe
OYcs Ly�u
I have mal
Ne vans mamuls mWimmemundr Chapmr6.95 df te Califon
sHalt&SafctyCod,Sceev205.25531nd25534.1 understand deterrence Wilding
d ouenm teNl
atit4mympmlbilitymnotifyrCdpNlmfe
neq eanwh
of P Signature of Applicant Date
Ownefwautherbudage^t D m' All roof coverings to be Class "ll or better