03050105 (2) CITY OF CUPERTINO '
BUILDING DIVISION PERT aCC0?a_1A. OR4INF, RMATPERMIT1 .
BUILDING ADDRESS: RUDOLPH & SLETTEN INC PERMITNO.03050105
i9n9i PRTTf11FRTn(-P. A177 J6)
IER'S NAME: 989 E HILLSDALE BLV `g6n"y`22/2003
1WLETT PACKARD CO_
PHONE: (415) 572-1919 SANITARY NO. CONTROL NO.
ARCHITEC rENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O O O 0
loo LICENSED CONTRACTOR'SDECLARATION Job Description
1HI hereby amne Nat 1 am licensed under pmviaions of Chapin 9(commencing
�H with Section 7010)ofDivislon S ofthe Busineuand Professions Cade.and my license is
a� Lnfull in=Clatur effect. Lic.« TI-COMPUTER RM REACTIVATION F�NALEO
j 82 Lkcrtse Clw
Dale Contractor
5 f' Li Idca
cam A ITDECLARATcION
siJm mnNs
d W
giddiag- DEC 0 12003
NER-BUILDER DECLARATION
I he any affirm that I am exempt from the CamranoYs License Law for the ' n
O O following memo.(Section 703 L5,Business and Professions Code:Any city or county BUILDING
3$ which requires a Permit m consider,alter,improve,demolish.or repair my structure
GPrior m its iuvena,atm requires the applicant for such permit in file a signed statement
nut he is licensed pursuant mthe provisionsofNeContractorsLicense Lave(ChaPur9 Sq.F[. Floor Area $30(Y"on
$ (commencing with Section 70W)(if Division S of the Business and ProfcsslnnsCWc)or
.. Nat he b exempt therefrom and the bub for du alleged exempdon.Any violation of
Section 7051.5 by any appliant fora permit maccu the applicant in s civil penalty of 3AM l9ftlfer 0 0 Occupancy Type
not mom Nm five hundred dollars(5500).
❑1.as owner Ofthe property,or my employees with wages as their ale compensation,
will do Newark and dre someone Is notinumded eroRemd for sale(See.70x4,Business Lui — FOUN
and Profeulou Cade:The Canuacmrs License Law don rot apply inan owner of 10 2 — P I ERS Inspections
property who builds or improves thereon,and who doumch work himselfor through his
own employees,provided thnsuch improvements arc not intended wortead formic.If. 103 — UFER
however,the building or Impmvammt Iamld within one year of completion,Ne matt.
builder will have the burden of proving that he did rot Mid or improve for purpose of 104 — REBAR
as.)' 105 - ANCHOR BOLTS
❑1,as Owner of the property,am exclusively contracting with licensed convectors to
construct the project(Sec.7044,Business and Professions Cade:)The Comrmmra U. 106 — SEWER & WATER
com law does oat apply on an Owner or property who builds or improve druaon.rod, 202 — UNDERFLOOR PLUMBING
Lwho icense Lawesfor such pmjecu wiNacanuumr(s)Iilicensed pursuant mthe Canuanoh 203 - UNDERFLOOR MECHANICAL
❑l am exempt under See. ,B&P C for this moan 204 - UNDERFLOOR FRAME
NCAgii, W u
WORK205 - UNDERFLOOR INSULATION
ER'S OMPENS TION DECLA
Thereby afford under penalty of perjury ane of the following declarations: 301 — ROUGH PLUMBING
❑Iheve and will mainuina CeniOcauaf Coaentmsel6laum for WohersCanpcn- 302 — TUB & OR SHOWER
cation,as provided for by Section 5700 of the labor Code,for the Performance of the 303 - ROUGH MECHANICAL
wed:for which this permit is issued. 304 - ROUGH ELECTRICAL
❑1 have and will maintain Workers Compensation lnsma
ur ,ss required by Section
5700 of the labor Code,far the perfarmana of the wart far whim Nis permit is issued. 305 — FRAME
My Worker,Compensation Insurance carie and Policy numbersm: 306 — HOLDOWNS
Carrier. Policy NFRO 307 - INSULATION
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 308 - SHEETROCK
(Thlsseetion need not becompleud ifthe Permit is forone hundaddollars(SIM) 309 - EXTERIOR LATH
1:cardJ 310 - INTERIOR LATH
I unify Nat in the Rormanee Of tite walk for t{nth this Permit u humid,I shell not
employ anyp r n'YOW �jatlntheworkerYCompensnion 311 — SCRATCH COAT
L.wa ar tali a 313 - ROOF NAIL
Appn m
Non O P I .If, ¢r makingthlsCcnificateofExemplion,youmould 501 - FINAL ELECTRICAL ENERGY
becoMe h' M Ne Workers Compcnation pmvisims of the lahm Cade,you mute
Msc
OZ rowiomplywithsuchprovisinns or this permit shall bedamedmvnked. 502 - FINAL PLUMBING ENERGY
ZO CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
[.n►
I heemby affirm that them is a construction lending agency for ft Performance of 504 - FINAL BUILDING ENERGY
IY>
the wurkrurwhich quit permit h;Wood(See.51D7,Civ.C.) 505 - FINAL ELECTRICAL
O Lenders Namc
5 z Under''Addre`s 506 - GAS TEST
U
U O I unify this I have rod this city
and county
and sum Nei the shove informationlis 507 - FINAL PLUMBING
U.0 E✓ Wilding
1 ague m comply with all city and coumy aNtunm and sou hws misting m
pU buirve-rconsuoction,and hembyauthadm repmxnutivp Otthiscity menmruPnn me 0C — FIN MEC ICAL
4S1 about-mentioned Properly for insPectian iocep hs. O f FI
Lay eWe)agree m ave.and expenses
and kap hay in m the City of Cupertino against
fA inconsequeneofthecesu and of this pa
which may in anyway ama geinstsaid City
U 7 A consequence of D Eng of this permit. !/,�,j�
r� APP ANT UND ANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: 5 LL MWcN.G.RKSDate
SO E C S.
22 Re-roofs
tilbiltine of Applicant/Conuacmr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding acupantsma or handle ha uadous material
u defined by the Cupertino Municipal Code,Clupter 9.12.and the Health and Safety
Semon 255724)?
❑Yu All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or�
If a roof is installed without first obtaining an inspection,I agree to remove
(�futureubuilding Occupant use equipment at devices whim
emit ha'rudnus air contaminants as derinc0 by the Bay Am Air Quality Management all new materials for inspection.
District?
❑Yes Pu
1 have mad the hmardws materialsmquiremcnuundcr Chapter b.95ofthe Glifory
nb HUIN&Safety Coo w25505,25555 and 25534.1 undersandthuifthe building -
doen oat mrcntly have em.that it b my responsibility a natty ties axupant nr Ne
apyui-q rats rami at met pnarmiaaana orace III to Signature of Applicant Date
wane araathamedasent Z Dam All roof coverings to be Class"B"or better