04010025 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMI. CONTRACTOR"INEORM
BwLDINGADDREsso RUDOLPH & SLETTEN' INC Pr"MIT"'04010025~'.
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY NO. CONTROL NO.
(415) 572-1919
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
woo Woff LICENSED CONTRACTOrp DECLARATION Job Description
1 rtby rpm that 13 licenme under provisions of Commop
Chapter 9(commencing
m with Section 7plU of Divistan3 of the Business Professions Code.and my license is
^?�, in full for"a
qz umanmcl Lle.✓� � DEMOLITION -
? Dam C.mre
ARCHI'IECI'S DIM 1 1
? I orders and my plain shall W dud sa Po records
G Licensed Professional
OW NSR-BUILDER DECLARATION
" I hereby affirm(hut I am exempt from,he Contractor's Licenm Law for IW
m O following reason.(Seed..712 1.5,Businesa and Professions Code:Any city m county
$9 which.quip.a permit to construct,site,improve,demolish.in.pair any mutt..
iprior to its issuance,also requires the applicant for Such permit to Me a signed statement
Cthat he Is licensed pursuant the provisions of dw Condutur �
a Limme, w(Chapor9 Sq.Ft.Floor Area Va
uluation
$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
that he m eumpt them(,.and the buss fm the aUnged ewnpdan.Any violation of
Section 7031.5 by a"appli"nl for a permit subjects the applicant to a civil penally of 3Y D1'tDIA7�er00 Occupancy Type
not ma.Nan five hundred dollars(5500).
❑L"own"of me property,or my employe"with wale"as their able compensation,
will d0 the W"k,.nd the$Wtl..Ian011ntended ar Offered for sale(Sec.7W,Bodeen
old Professions Code:The Contractor's License Law don not apply m an owner of C�equircd Inspections
property,who builds or improves themon,and who do"auch work himself or through his
own emplayna,provided that such improvements are notimmnded mortared for We.If.
however,the building or improvement la sold within one yew of completion,Ne owner•
builder will have she bonds.of pmving that he did no,Wild ar improve for premum of
Const.
❑1.as owner of the protan.am esclusively contracting with licensed contractors in
Construct a the prole"(Sec.to in weer of.and Profesruefully
whoa.Code:)The Conwctos, nd
whocontracts Low coca not apply e ts owner of property who Wilda or improves Commas and
who.. for such projects with a conlnnor(a)limed pursuant m the Conuaetofa . .
License Law,
❑lam,sump,under lee ,B&PCfor this rtuon
vena Data
WORKERS COMPENSATION DECLARATION
1 hereby alarm under penalty of perjury,one of the following dataretiou:
I have and will mainutin a CeniO"m of Conunt mulf-insure for Worker's Compel.
tion,u provided for by Section 3700 of the Labor Cade.fm We Performance of the
work for which this permit is issued.
❑1 have and will maintain Workefa Compensation Insurance,u rationed by Section
3700 of the IA Wr Corte.for We performane,of the wort f"which this Permit is issued.
My Wo eta Compe"nsationlnaummectniere Pal' numberam: �.�
Cat�ser� E41Vwsn i o.: WL.'t s{q S.7u s
IY CERTIFICATE OF E%EMPT70 OM WORKERS'
COMPENSATION INSURANCE
(Thmscaian recd on,W completed If to Permit is for one hundred dollen(SIM)
or leas.)
I certify,that in the performance of the work for which this Permit is issued,I shall not
employ any person in any manner an u to become subject to the Workere'Compensation
Lawn of Celifomia.Date
Applicam
NOTICE TO APPLICANT:IL spur making this Certificate of Exemption,you Mould
become subject W Ne Worker's Compensation provisions of the Labor Code.you mot
OZ forthwith comply with such provisions w dimmed
thio permit shall W "med raveled.
,zi0 CONSTRUCTION LENDING AGENCY
(-4 1 he.hy a(Itrm Our Wert its ronstmctlnn lending agency for the perform me,of
li�,7 the work for which his;permit is issued(S".3197.Co.C.)
0.Q Undue,Name
.7 z Leader',Address _
U Q I minify that i have.ad this amplitude.Wrote than the W.infmrrhuim is
[2s F cones.I agree in comply with all city and county ordinances and sum laws misting to
Q V building construction.and hereby sumotm repremma fives of this city to enter drum We
w It1 above-mentioned Interparty for inspection purposes.
t„ G (We)agree m save.indemnify sed k"P harmlus me City of Cupertino against 1
C+f/) liabilities, gmonts.costs and expenses which may in anyway accrue against said City
V inconmq a of lie granting of this permit.
APPLIC NDER AND WILL COMPLY WITH L NON-POINT Issued by: Date
SOUR R G ATI S t
Sign.rt o Ap icanVComrulor Date Rc-roofs
HAZARDOU MATERIALS DISCLOSURE Type of Roof
WV aapplieant.rfulure filling occupant store m handle hwudous material
sa denned by the CupeNn.Municipal Code,Chapter 9.12,and the Health and Safety
Cole.Section 25532(a)7 �u All roofs shall be inspected prior to any roofing material being installed.
❑Ym K.
Will the applicant or fuuo\m building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Id=
t haurdous air c.nmmimns u&fined by the Bay Amo Air Quality Management all new materials for inspection.
ics?
❑Yea d
I have srdresmamriais rtqui.mcnu underCMpter6.95 of the Calif.,.
HmIth& of y ,SeNom25505.25533 and 2553/.I undcrsund that iflhe Wilding
not c nl ve tenon Net u my r"pomibi111y m uhdfy the occupmt of We
lmmc w hm. W t '.rt i .anceafaCepop fOcm.p r. Signature of Applicant - Date
O
adm.'v d se.t p,p All roof coverings to be Class"B"or better
gNe--r
CITY OF CUPERTINO
1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 3
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 31607046 . 00
DATE ISSUED. . . . . . . : 01/08/2004
RECEIPT # - - . . . . . . . : 24167
REFERENCE ID # . . . : 04010025
SITE ADDRESS . . . . . : 19091 PRUNERIDGE AVE
SUBDIVISION . . . . . .
CITY
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : HEWLETT PACKARD CO.
ADDRESS . . . . . . . . . . : 19091 PRUNERIDGE AVE
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : RUDOLPH AND SLETTEN
CONTRACTOR . . . . . . . : RUDOLPH, ALLEN LIC # 5335
COMPANY . . . . . . . . . . : RUDOLPH & SLETTEN INC
ADDRESS . . . . . . . . . . : 989 E HILLSDALE BLV
CITY/STATE/ZIP . . . : FOSTER CITY, CA 94404
TELEPHONE . . . . . . . . : (415) 572-1919
EE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
- --------- ------------- ---------- --------- - ---------- ---------- - ---------
BPERMFEE VALUATION 209, 000 . 00 1224 . 00 0 . 00 1224 . 00 0 . 00
BPLANCHK PERMIT FEE 1, 224 . 00 1040 . 40 0 . 00 1040 .40 0 . 00
BSEISMICOM VALUATION 209, 000 . 00 43 . 89 0 . 00 43 . 89 0 . 00
---------- ------ - --- ---------- ----------
TOTAL PERMIT 2308 . 29 0 . 00 2308 . 29 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
--------- - ------- ------------ ------------------
CHECK 2308 . 29 725147
TOTAL RECEIPT 2308 . 29
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-=704=== DEMO________________________
&CITY OF CUPERTIN
DEMO %,
CUPEII; TINO PERMIT APPLICATION FORM
APN# 3 / 6 — 07 - 0(-16 ,
d7 - 0(-16 ' Date:
Building Ad ess: rj
I Y �(�G ✓ r
Owner's Name: Phone#•
Contractor: License#jjocn- pit :
Contact: Phone
A6,13('06Z5 Phyte
Applicant/Contractor:
uilg Pe t Info:
Bld ect b Mech
ptiom �—
Residential: Commercial:
Sq.Ft. Floor ea: q.Ft.:
Architect/Engineer: Valuati
Type of Construction: u Group:
Qtyxif-
AppfcaM Fee ID Fee Description Fee Group
BPERWEE Bldg Permit Fees BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
BSEISMICRE Seismic Residential BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG
$a3 � 2/