02120051 CITY OF CUPERTINO
BUILDING:DIVISION PERMIT CONTRACTOR INFORMATION:.
BU U.DING ADDRESS: RUDOLPH & SLETTEN INC PERMITNO.
10435 N TANTAU AV
HR'S NAME: 989 E HILLSDALE BLV APPLICATION SUB DATE
P 12/12/2002
PHONE: (415) 572-1919 SANITARY NO. CONTROL NO.
ARCHITECI?ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�Op Lm thatIDCONTRACn&, rovi.Cittof CON Job Description
y18 1 hereby efRrm that I on licensed under provisions of Chapter 9(rommesming p
wish SeCllta7.1)O of Division 3 of dm Business. Professions Onk.and my license is
� ,� intuit I. (a an re DEMO (6000 SQ. FT. )
Liccnsc C)m Lic.p
O N ante Const sr
^^—q� ARCHITECTSD A 1
$ untlersand y plans shall W used as public records
dO�U
.C Licensed Pro(cssinnal
OWNER-BUILDER DECLARATION
u�n 0 1 hereby marri .?Hemi that 1 1. exempt from the Convectors Code:
License city
o for the
iSpO followingrcuon.Permit
]031.5,Businessand vefdemols Galt:Any city nrruunty
a�$ which requires a permit re quires the alter.improve,demolish,or repair any structure
prior bt its Tensed p also requires the applicant for such permit m ice s signed statement
thaWiscing with
pursuant 70the pnrvivisio of the Contractor's License loons Code)or Sq. Ft. Floor Area $356'i11GAtion
$
(commencing with Scminn]INk)7 nl Divisian7nfthe Business and Professions GNc)or
.. Nat he is exempt Ihemfrom and the basis for the alleged exemption.Any violation of
Section]031.5 by any applicant for a permit subjects the applicants to a civil penalty ofOccupancy Type
not more than five hundred della.(S50T.
Q I,as owner of the properly,or my employees with wages aa[hair mile compensation, NE) ASSIGN I
will do the work,and the structure is not intended or offered far sale(Sec.]OCC,Business EfDV
and Professor.Code:The Contractor's License low does not apply to an owner of egnlfe nspeCll0n5
properly who builds or improves thereon,and who dmaauch work himself.,through his •�,
n employees,provided that such improvements are not intended or offered forralle.IL •�.a:f
however,the building or improvement is sold within one year of completion,the owner-
builder will have dee burden of proving that he did not Wild or improve fur purpose of
.IsL f, f —.•J
❑1,as owner of the prolixity.am exchrovely contracting with licensed comments to -
construct the project(Sec.]OCC,Business and Professions Cade)The Contec[or's Li- I
cense Law does not apply to an owner of property who Wilds or improves themnn,and
who contracts for such projects with a conrusor(s)licensed pursuant to the Contractor's
License Law. I
❑1 am exempt under Sec. .B&P C for this resson r
Data40-1 1
WORKER'S COMPENSATION DECLARATION
I hereby a?mt under penally of perjury one of the following decluations:
❑ I have and will maintain a Certificate ofConsent mself insumfor Worker's Compen-
sation,as provided for by Section 37(1)of the Labor Code,for the performance of the
work for which his pemot is issued.
❑I have and will maintain Workers Compensation Insurance.as naluimd by Section
37N)of the ISWr Code,for the performance of the work for which this permit is issued.
My Worker's Compensation IInnssumnce carrier and Policy numWf r4,,q07,
Cam:Ba M GVIk�?!LI&Bi Policy No.: 33 TT .Y
e( CERTIFICAT Op LXEMPr10NP ORKERS'
COMPENSATION INS)R N E
(This section need not W completed if the Permit is forone mo dreddollars(SHO)
text.)
1 cenify Net in she performance of Ne work for which Nis permit is issued,I shall not
employ any parson in any manner m as[t become mance,to the Workers'Compensation
Laws of Califtmm.Data
Applicant
NOTICE TO APPLICANT:If,after making this Cenilicme alExemption,you should
become subject to the Workers Compensation provisions of the L WY Code,you mum
Oz forthwith comply with suchpmviaim.or this North hall W deemed mvnked.
O CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a constitution lending agency for the performance of
6i the work for which Nis permit is issued(Sec.3187.Co.C)
QLattice,Name
C z Lender's Address
U C 1 cenify that 1 have read this application and smm that the above information is
L4 F comet.I agree to comply with all city and county ordinances and smm laws minting to
O U building construction,and hereby auNnne,repicacnutivcs of this city to enter upon the,
W abmvcmentioned progeny for inspection purposes.
(We)agree m save,indemnify and keep harmless the City of Cupcnino against
V) liabilities,judgment,costs and expenses which may in any way new against said City _ )
U 7 in consequence of the granting of this permil. a11�/
CI APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ONP INT Issued by: at
SOU GULATIONS.
J6 zAzt al Re-roofs
em.of Appli ✓c.rommnr Dam
AZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant store or handle havardoua material
defined by the Cupenino Municipal ,Chapter 9.12,and the Health and Safety
da,Se❑ctYnnn 25532(.)1 All roofs shall be inspected prior to any roofing material being installed.
es
Will Nc applicant or future Wildin �pan[Bae egaipmenl or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit he...doua air cunamiwnts u Jcfi by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Ycs
I have mal the hat usb isle rryunomms under Chop.r6.95ofthe Cmifor-
niall"Illa(myGWc, dL25N53,25533 and 25534.1 undersand da[if the,Wilding
does nn[currently hose a arrant,Na[i[is my respmsihility m nodly d¢mCup t numb.
rcquirc c�which most Wm at pit su
isanccef.Cenirwoa 11 'upomy Signature of Applicant Date
wt�eF` ume,ie�ebl��J has All roof coverings to be Class"B" or better