03090179 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACT(?R INFORMATI(7lL�T
LDING ADDRESS: RUDOLPH & SLETTEN INC PERMIT N003090179
'S NAME: 989 E HILLSDALE BLV PERMITLSSUEDATE
- HP BL
PHONE: (415) 572-1919 SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
100 LICENSED CONTRACTOR'S DECLARATION
w I hyyrcby affirm That I am he wed under provisions of Chapter 9(commencing Job Description
�i� with Stg}pn]fvkp of Division] fth sines and Professions Codc,and my license is
ZL,mlYk.PPd�-ee and IT t. n ` 19 -09 TI--ADDISON AVENUE FOR CREDO UNION
Licensc CI s L¢.N
�y p Date (,9 Conlracc r NA L
4wtai /:K J�.dera ipmna eni�uscd pontic reco�� - �®
Lie Professional MAY 1 0
c0� OWNER-BUILDER DECLARATION 2004
�<Y 1 hereby affirm Iha(1 em ucmpc from Our Contractor's License Law for the
OO following reason.(Section 711316,Business and Professions Code:Any city or county
Z
m� which requires a petmil hi construct,alter,improve,demolish,or repair any structum
prior In its issuance,also requires the applicant forspeh Permiuo file adgocd statement
eZt¢ that he is licensed pursuant to the provisions of the Contractor's License Law(&Pter9 Sq. Ft. Floor Area Ann
`t$ (commencing with Section 7000)of Division]of the B usiness and Professions Code)to
3
Out he is exempt therefrom and Ne basis for Ne alleged exemption.Any violation of 31607045 . 00
Section?031.5 by any applicant for a permit subjects the applicant to a civil Penally of APN Number Occupancy Type
not more khan five hundred dollar.(s5W). - - - - .. -- .. - -- --' P Y ---
❑I.as owner or the property,or my employees with wages as their sole compensation,
will do the work,and the swchim is not intended or offered for sale(Sec.70,14,Business —
and Profession,Codc:The Contractors License Law does not apply to an owner of 102 . - PIERS d Inspections
property who builds or improves tbconit and who does such work himself or through his
own employees,provided that such improvements are not intended oroffered for sale.if, 103 — UFER
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving Nat W did not Wild or improve for purpose of 104 - REBAR
able)' 105 - ANCHOR BOLTS
❑I,as owner of rhe property,am exclusively contracting with licensed contractors l0 10 6 - SEWER & WATER
construct the project(Sec.7074,Business and Professions Cotler)The Contractor's Li
cense Law does not apply to an owner of property who Wilds or improves themon,and. 202 - UNDERFLOOR PLUMBING
Itiontractsfor such projects with a contractor(s)licensed pumaantto the Cmilmebra
e Law. 203 - UNDERFLOOR MECHANICAL
in exempt under Sec. ,B&P C for this reason 204 - UNDERFLOOR FRAME
Data 205 - UNDERFLOOR INSULATION
- WORKER'S COMPENSATION DECLARATION
I hereby atfinn under Penalty of perjury one of the following declarations: 301 — ROUGH PLUMBING
ave and will maintain a Coni fiat,of Consent to self-insure for Worker's Compen- 302 — TUB & OR SHOWER
m provided for by Section 37W of the labor Code,for the perfmmancc of the 303 - ROUGH MECHANICAL
or which Nis permit is issued:
ave and will maintain Worker's Compensation Insurance,as required by Section 3 04 - ROUGH ELECTRICAL
of the labor Code,(or rho performance or He work for which this Permit is issued. 305 — FRAME
Myw er'sCompensation lnsunncccagicrannd�orli Wrare: 306 - HOEDOWNS
C ./-1NEWCnN�t.aPUIP/�ii CC+9Polic _
CERTIFICATE OFEPr10Nr ROM WORKERS' 307 — INSULATION
COMPENSATION INSURANCE 308 — SHEETROCK
Or (Thu section need not W completed if the Permit is for one hundred dollars IS I010 309 - EXTERIOR LATH
Icenia.) 310 - INTERIOR LATH
employ
Nat in the performance of the work for which this permit is issued,l shall not
employ C.lif son in any manner an aswhecomesubjuuo the Workers'CnmPensadon 311 — SCRATCH COAT
Laws A,pEcr GeHlornia.Dote 313 - ROOF NAIL
APPiicank
NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should 501 — FINAL ELECTRICAL ENERGY
become subject to the Worker's Compensation previsions of the Labor Code,you must
>Z forthwith comply with such provisions mthis Permit shall the deemed revoked. 502 - FINAL PLUMBING ENERGY
Z O CONSTRUCTION LENDING AGENCY 503 — FINAL MECHANICAL ENERGY
I hnchy alTom Nae there isoro®tructinn lcndiogagemy for the performance of 504 - FINAL BUILDING ENERGY
z> 00 work urwhich this permit isi ucd(Scc.J0)7,Civ.CJ 505 - FINAL ELECTRICAL
S) A Lender's Add
� Z Lnea'sAddrcs 506 - GAS TEST
7 p I certify that I ban read this appllcalion and stale that the above Information is 507 - FINAL PLUMBING
E' torten.1 agree to comply with all city and county ordinances and state laws relating to
U building construction,and hereby authinto representatives of this city to enter upon the AF
MEC CAL
'hove-menkitned proki for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against 9 Hadlidio.judgrocro,costs and expenses which may in anywayaccmeagainusamCityC, , NG
U Z in consequence of Ne granting urchispermit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL'y/,,•OWPOINT Issued by:5 C WORKS Date
SOURCE REGULATIONS. �.�/ /
Re-roofs
Sig
ore of ApplicanVConlracl Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle haysrduus material
.fined by the Cupertino Municipal Cede.Chapter 9.12,and the Health and Safety
.
Section 25532(a)?❑Ycs 'RN. All roofs shall be inspected prior to any roofing material being installed.
Will due applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit ha ardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Distriel?
❑Yes 'RN.
I have read the hovaddusmamriab requirements uwcr Chapter 6.95 of the Califor.
nibHealth&Safety Cedc,Sections25505,2553J and 25534.1 understand Over iIft Wilding
does not cuncnny have a totem,that it is my responsibility w notify c occupant of the
require c which moat bemekpnurwissuancenfaCaniflua nr u r Signature of Applicant Date
O ur auchori'reJ egcm Dam
r All roof coverings to be Class "B" or better