02120050 CITY OF CUPEWrlNo
BUILDING DIVISION PERMIT CONTRACTOR.INFQRMATION:•.'.
BUR.DINGADDRIZSS: RUDOLPH & SLETTEN INC PERMrrNO.
10435 N TANTAU AV 02120050
OWNER'S NAME: 989 E HILLSDALE BLV APPLICATION SUB DATE
HP 12/12/2002
'ONE: (415) 572-1919 SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
w00 LICENSED CONTRACTOR'S DECLARATION
F I herchy firm that 1 am It and r provisions of CbapI 9(commencing Job Description
with Section7( g)of Divisinn3oft Bound Pnsfessiens C,de,andmylicommis
nrmtn mrct aG�trmml„ /93,06 TENANT IMPROVEMENT
z CLI i Liccnsc Chm4r L� Lic.N_
C.
O W a 1 undccsl:md m3,AlunµAlull M N nspuhl a rccmds '
MAR
R o s Zoos
m LL1� Licensed Pnmlesxinnal
OWNER-BUILDER exempt!farm
Rue RATION
u�00 1 hereby affirm on 1 L. exempt from the Contractor's License Law for the BUILDING
i S OO following recta n,(Section 817 1.5,Business and Professions h,or Any city or county
K$ which requires a Permit m nmstrucl,alter,improve.demolish,or repair any structure
1O prior o its issuance,also requires the applicant for such permit to Glc a signed statement
that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 Sq,Ft. Floor Area $2 8 019`00ition
(commencing with Section 7000)of Division 3 of NC B traders and Professions Code)or
y Nat he is exempt Ihmafrom and the hast for the alleged exemption.Any violation of
Section 7031.5 by any applicant far a Permit subjects the applicant to a civil penalty of Occupancy Type
net more Nm(e hundred dollars(5500).
0 1,as owner of the property,or my employees with wages a their able compensation,
will do the work,and the structure is not intended or offered for We(Sec.71144.Basin.
and Professions Code:The Contracto's License Law does not apply to an owner of10 2 - P I ERS equ3red Inspections
property who builds or improve thereon,and whodoes such work himself ormrough his
own employees,provided that such improvements ate not intended oroRered!orale.If. 103 — UFER
however,the building or improvement is sold within one year ofcompletion.me owned 104 — REBAR
builder will have the burden of proving that he did not build or improve for purpose of
sale.). 105 - ANCHOR BOLTS
01.as owner of me property,am exclusively contracting with licensed convectors to 106 - SEWER & WATER
consumer the project(Sec.7W,Businem and Professions Code:)no Contractor's U.
cense law does not apply to an owner of property who builds or improves Random.and 202 — UNDERFLOOR PLUMBING
who contracts for such projects with a contractor(s)licensed pursuant to the Cemracmr'a
License Law. 203 - UNDERFLOOR MECHANICAL
❑ I am exempt under Sec. ,B&P C Tor this reason 204 - UNDERFLOOR FRAME
caner Date 205 - UNDERFLOOR INSULATION
WORKER'S COMPENSATIONDECLARATION 301 — ROUGH PLUMBING
I hereby alTnn under penally of perjury one of the following declarations: 3OZ — TUB & DR SHOWER
Inave pnd rovide for
mountainate ofC Letter Codeent to .foternrerform'a Cumpcm 303 — ROUGH MECHANICAL
ration,a provided for by Section 77fN1 of the labor Code,for the Performance of the
work( which this Admit it issued. 304 - ROUGH ELECTRICAL
0 I have and will maintain Worker's Compensation Insurance,as required by Section 305 - FRAME
37M of the Labor Code,for the performance of the work for which this permit is issued
My Worke' Compen9ation Ins m,ctioncr and Policy number am: . -4 306 - HOLDOWNS
Ca r: se e Pmiey No.: 307 - INSULATION
CERTIPICATF.OF EX Pr10N FROMW ERS'
COMPENS TION INSURANCE 308 — SHEETROCK
('(itis section need not be completed if the permit is for one hundred dollars(SINh 309 - EXTERIOR LATH
mlCAs.) 310 - INTERIOR LATH
I certify mal in the performance of the work for which this permit is issued.I shall nor 311 - SCRATCH COAT
employ any Person in any manner ab as to become subject e the Workers'Compensation
Laws of California.Date 313 - ROOF NAIL
Applicant
NOTICE TO APPLICANT.-If.after making this Certificate of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
become subject o the Worker's Compensation provisions of the Labor Code.you must 502 - FINAL PLUMBING ENERGY
OO f,nhwith comply with such provisions or this Permit shall M deemed revoked.
z CONSI'RUCI'[ON LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
14 1 hereby affirm ram them is a conallection lending agency for the Performance ol 504 - FINAL BUILDING ENERGY
rs, > the work fm which fikpond iIaissued(see.YAP,Civ.C.)
Lcndc505 - FINAL ELECTRICAL
W 0 r's Namc
aZ Lcnder'sAddress 506 - GAS TEST
U O 1 certify that I have read this application and state mat the show information is 507 - FINAL PLUMBING
W H cored.Iagree tocomply with all city and county coimncesand state laws rclmingto 5 FINAL MECHANICAL
O building conswcrion,and hereby aurhrrire mpresephadws of this city m enter upon the
� W above-mentioned pruperry for inspectinn purposes. 09 FIN DE
F-t O' (We)agree to save.indemnify and keep harmless the City of Cupertino against
(n liebi li( judgments,costs end expenses which may in any way accrue against aid City 5 N Gm t� >
V z in co tenccof the granting of this permit.
t-^ APP Nr NDF.RS Nos AND WILL COMPLY WITH ALL NON POINT Issued by5 1 WORKS Date
s0 ATIO
Re-roofs
recf Ap manv.orit Data
1 LARDQD$MATERIAISDI$GLQSDRE Type of Roof
Willthcappl'antor future building occupant store or handle haalloux material
as defined by I penin,Municipal Coale.Chapter 9.12,and the Health and Safety
Cndc.Section 2 .2(a)'f �/ All roofs shall be inspected prior to an roofing material beim installed.
❑Yen r No P P Y g g
Will the applicant nr future building occupam use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
crit hammome;air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
DYcs 21No
have..thc to mousmaterials requirements under Chapter 6.95ser the Cali lot.
null th SctyCodu,G:Iinnx255115,25533am25534.1 andnrsmn thairthc building
J I t tly have a I ant,tha i1 is my resrymribility m nomy I cupwl nl the
shmust a tetpriermirauanecora Ccludicatemr Deets Signature of Applicant Date
i Ow nv amhnrire agent etc All roof coverings to be Class aBa Or better