06090005 CITY OF CUPERTINOt-8' .°A
BUILDING DIVISION PERMITCONTRACTCIR=INFO$MA.TION
,5.. bpi " p: `.$'
BUILDING ADDRESS: RUDOLPH & SLETTEN INC PERMIT NO.06090005
19111 PRUNERIDGE AVE
R'S NAME: PERMIT ISSUE DATE
HEWLETT-PACKARD COMPANY 1600 SEAPORT BLVD STE 35 09/21/2006
P NE: SANITARY NO. CONTROL NO.
(650) 216-3643
ARCHITECT/ENGINEER: BUIIDINO PERMIT INFO
BLDG EIFCf PLUMB MECH
i00 LICENSED CONTRACTOR'S DECLARATION Job Description
I— I street,ofB�dal 1 am licensed under povidone of ClmPmr 9(ammenring P
�IG with Section 70f)0)otDivision 3 of NC Business and Profession Code,and my license is
?"e in full force andeffcec REVISION-TO STRUCTURAL & FIRE RATED MATERIAL &
'az aneseclau Lic.t.a
Dam10 car PENETRATIONS AS WELL AS MECHANICAL
D
if� ARCHITECTS DECARATION ORIGINAL PERMIT 406050126
i es< 1 urdercund my P�adult tee used ss public raords
aiU
'n t; Licensed Pmfeuiaral
0, OWNER-BUILDER DECLARATION
in JI be¢by air,.that 1 am from the frothe CommitteesLicense Law for the
20 following reason.(Section 1031.5.Business and Profession Cade:Any city or county
m which requires a permit or,eonswet,ales,improve,demolish,or repair any structure
¢i prior m its lsauance.also requires the applicant far such Permit m file a signed eutement
O that M u licensed pursuant to the provision of the Contractor's Licensee law(Chapter9 Sq.FL Floor Area Valuation
(commenringwithSection 7000)MDivision 3rd'the Buan
icsand ProfrsinnCode)or $7000000
— that he or exempt therefrom and the baso for the alleged exemption.Any violation of
Section 7031.3 by arty applicant far.permit subjects en applicant to a mil penalty of APN Number Occupancy Type
not mum dun 0w hundred dollars(s5f10).
❑1.as owner of the property.or my ereployces with wages as their sole compensation,
will do the k,and thwm
esctuu mor intended or offered ser aak(See 7044,Busircss
work, Required Inspections
and Profession Cade:The Contractor's Liam Law does not apply m an owner of q P
property who builds orimproves thereon,andwha doessuch work himselforNmugh his
own employees,provided that such improvements am not imerbW oroffemd forsale.IL
however,the building or improwment or sold within ane year of completion,the owner.
builder will have the burden of proving that be did eat build or improw for pur,aue of
sale.).
1,as mmar of the Property.on exclusively contracting with licensed cmearic an m
tract the project(Sec.70x4,Business and Protection Cade:)The Conmcmfs Li-
cone law sora not apply to an owner of property who builds or improns demon,and
who contracts for such projects with a conmcror(s)licensed punuanl m the Conaracror's
License Law. (\,
❑lam axe Dt der See .B A P C for this once
I Dao a1. ec
ORI OMPENSATION DECLARATION S a�
1 nee Y ami under pnniry of perjury,one or the following dan
letion:
I]Ihaw and will maintain aCerdGnmof Consentmself-inure for Workeh Compen. J
cation,as provided for by Sce,un.3700 of the labor Cade.for the perrmmance of the
work for which this Permit is Lssund.
ZI 1 have and will maintain Workeri Compensation Insurance,a required by Section
3700 of Ne fator Ced,for me performance of the wank for which door permit is inbod.
My Worker's Comparisons Insurance artier and Policy number art:
Carrier. Policy No.:
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
(Thu sectio bond rothe completed if the parent,is We.hundred d.11.($1018
or lass)
1 certify thst in the performance of the work for which this Permit is issued.I shall net
employ any pg y l ism kat, jy L3tpe Workers'Compcnsauon
laws ofcslit ia. m _1�1•Vb
Applicant A
NOTICE TO r making this Certificate of Exemption,you should
become mtjcct the Wohc i C0 pgnankin provisions of the lalwr Cade,you most
.J z foMwith comply with such provision or this permit shall W deemed mwki
r O CONSTRUCTION LENDING AGENCY
rC+ I hereby affirm that then u a cormrucumn lending agency far dc performance of
ata 7 Ne work for which this permit u issued(Sec.3091,Civ.C.)
lender's Name
D z Lcn&es Address
V Q I cenify that 1 haw read Nis application and stain that the above information is
IL toren.1 agree to comply with all city and county ordinances and sum laws mlating to
0 building consuuniam,and hereby terrorize represcnutins of this city to enter upon the
r ahrrg-meenhugm judgments.
costs
for inspection ns pur,whichscs.
(Wee)agree m saw,indemnify and keep harmless the City of Cupertino against
F" Z incontiesunce of the granting of this Permit. may in any wayaccrue regains said City
t.)z in consequence of the granting of Nu permit.
^ AP CANT UN STANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
U ER. U ONS.
Re-roofs
Stratum of A*IilSudn70mlfanmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
W111 theapplicantor(seMum Wildinge.Chase,9.1m handle Health
material
dehSection
ec by dt 32(a)?ata Municipal Code.Chapter 9.12,and et HuIN and Safety
Se y.us3z(a>" All roofs shall be inspected prior to any roofing material being installed.
❑Yes �fJr
I� If a roof is installed without first obtainingan inspection,I agree to remove
Will ern applicant m future building by dee B sew ea Air(mor Mara which P g
emit hvaNrn air contaminants n defined by the Bay Arca Air Quality Management all new materials for inspection.
District? ��rk ec
P
❑Yes x3nu
1 have mind the haranhour materials requirements under CTupmr6.95 of the Califor-
nia aIth&Safcl,Code.S<cdrn2M5,25533ld25534,1undcnwdllif Lhcb.ildi.,
J 4hamnnr,Nat it u my msponiMlity m notify Nn occupant of Neem ire imetpmorm issuanaofacemfettearac sney Signature of Applicant Date
�own rrraD„e All roof coverings to be Class"B”or better