02110056 (2) CITY OF CUPEWrINO
BUILDING DIVISION PER ,,,CONTRACTOR INFpRM ON'.,,
BUI 13EsPRUNERIDGE AV RUDOLPH & SLETTEN INC PERMIT NO 2110056
'114EMbETT-PACKARD COMPANY 989 E HILLSDALE BLV APPLICAT!/fiSPUTJ2002
Pit,NE: (415) 572-1919 SANITARY NO./ CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLOC ELECT PLUMB MECH
t�
�00 LICENSED CONTRACT'OR'S DECLARATION
�u� IMmbyaffirmthmlamlicensed under provisions ofChapter 9(commcncit, DEMO (BLDG #44�bDescription
tn< with Section 701M)of Gloria Sof Ne B....,% hnd Prefeasions CNe,and my hear.is
t- iofulllbmca eft r FEES $6797 . 65 PAID WITH #02080131
FN�? License Lic.M
,_ Contmctnr
� QQ ARCHITECT'SRATION
pZ I understand my plans shall M unci uhlic records
apd0
LLO Licensed Professional
OW NF.w BUILDER DECLARATION
u�<E I hereby mason.(Sect that 1 1. exempt Gum the Commnora :Any c Law for the
�ia_p0 followWhichingtimes. f(Section construct,altessandl'm, isions demlih,oc:Any city rr«mnty
$ which rcyuires a Not re iduthealter,improve,h perwitt or repair any structure $840000
poor to its issuance,also ntin be provisions
fee sucContractor's
Licefile a nse Lned aw
s�ss< that he is licensed pursuammtM provisions of the Contmner's License law lChapm,9 Sq. Ft. Floor Area Valuation
FS (commencingwith Section 70(10ofDivision 3ofthe Business and PromminnsCode)or 31607034 . 00
rc3— that M u esame,therefrom and the basis for dm alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mem than Live hundred dotl...(S5f101' NO ASSIGNED INSPEC IONS
I,u owner of the propeny.or my employers with wages u their sok compensation,
will do Ne work,and dm su name is not intended or offered for sale(Sec.7W,Business
and Professions Code:The Co muscrors License Law does not apply to an rower of Required Inspections
Property who builds or improves tMmon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered foraele.If,
however,Ne building or improvement is sold within one year of completion,Ne owner
builder will have the burden of proving that M did not build in improve for purpom of
sale.).
❑1,as owner of the progeny,am exclusively contracting wish licensed contractor to
cmuuuct the project(Sce.7044,Busineu and Professions Code:)The Comma tots Li-
ss,law does not apply to an owner of progeny who builds or improves themon,and
who contracts for such projects with a conuactor(s)licensed par suam m dm Contractor's
Lt..Law.
❑1 am exempt under Sec. .B&P C for this moon
Dare
4 Ir WORKER'S COMPENSATION DECLARATION
I hereby aBimt under penalty of perjury one of the fallowing declarations:
❑I have and will mutation a CeriRcate of Consent o self-insure for Worker's Cempom
cation,as provided for by Section 37M of the labor Code,for the perturmance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,m required by Section
37M of the labor Code,for the performance of on work for which this permit is issued.
MyWr is Compensation In...ce career,a�nm,Pj ,nu ties.:_,
a r. CC&-tC1ta�CilA�t'so Id�yts' . � � C� I
CERTIFICATE OF EXEMPTION FRO WORKERS
COMPENSATION INSURA CE-.,.,(ThissectiunnecdnmMcompletedifthepermit' on talreddellara($1 I
nr less.)1 eerily that in the perlbrmance of the work for which . ed.I I Fri
employ any perum in any mannermMto bocome suhje a .1 rs,Compareation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making Nts Campeau,of Exemption,you should
become subject to the Workers Compensation provisions of the labor Code,you must
O Z forthwith comply with suchpmrskimm,or this permit shall be deemed revoked.
z O CONSTRUCTION LENDING AGENCY
I hereby ullirm dim,there is a construction lending agency firths,performance of
Cli 7 the work for which this permit is issued(Sec.3099,Civ.C.)
W� Q Leoders Namc
z Lender's Address
V 0 1 cenify Nat I have mad Nis application and sole that the above information is
ly U.l.l agree to comply with all city and county ordinances and slam lawarelating to
DU building construction,and hereby amhodm representatives of this city to enter upon the
above mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
y liobilitics' Og' no,cosesa expenses which may in any way accmc against said City
V z APPLIe A nceUltDe RSTr g f IANhis��11 L CO PLY WITH ALL NON INT Issued by: Date (}�
SOURC GU ONS Ik
Re-roofs
amrc of Applicano tmrcror Date
HA ARDOU MATERIALS ISCLOSURE Type of Roof
Will the applicant future ildingoccup t store ser handle mortalmammal
as defined by the Cupertino atipal Gale,Ch pier 9.13,and the Health and Safety
We'
Section 35532(.)7 a� All roofs shall be inspected prior to any roofing material being installed.
❑Yes �t Nr
Will the applicant Or building Occupant equipment or devices which If a roof is installed without firs[obtaining an inspection, I agree to remove
emit haeardnus air contaminants as defined by Ne Bay Arca Air Quality Management all new materials for inspection.
District/
CS �Jo
mad rbc harNnu 'amnalsmyuircmcnks under Chapter 6.95 of the Calibre
win Hca vSafety(Sca,Seco sSN)5,3553 34.1unJcrmnd Natifshe Mil 'ng
she.n c rent Mex sone tit is my nmtb ity to notify the nccup.,of c
regaim e w emu rte tp- Ly ter a mrr0.x anoy. o9ignatureofApplicant Date
0 o,informedagcnl kaj All roof coverings to be Class "B" or better