05030163 (2) CITY OFCUPERTINO yy' *e . '�ZE� •�" T`%� "K'n�'^' ` '^""
BUILDING DIVISION PERMIT ".'CONTRACTORdNTN'URMATION
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BUILDING ADDRESS: RUDOLPH & SLETTEN INC PeRMIT ND05030163
OWNER'S NAME: PERMIT huUE DATE
NE: SANITARY0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
t�
O LICENSED CONTRACTOR'S DECLARATION Job Descr 11 In
I Wrtby malrm that l am handed under provisions of Chapter 9(commencing
with Section 7000)ofDivlsion 3 ofthe Business dProfcsslun Codo.andmy licenuis
in full farm end off
�_ `5 13 � oL TI--ADD BREAK OUT ROOM
S t.cc leu CmY
Dew '4A.-t,neS TSDE L u ^� AUG 2r 2005
ARCHITECTS DECLARATION
I understand my Ptsu shall W used ss public rtards
5 Licensed Profcat...I �@gp}�{qt
o OWNER-BUILDER DECLARATION I L Y lRtl
r.a 0 I Wmny.(Som on 11. exempt from the ficsol Co License Law for the li WWW
i p o which co reason. e mtiu]fnl.s,Business and me,demolish.aioes m Any can err manly
$ which rtquis a•permit re uirei cis aper,Improve,hPermittri repair any mmcwrt
t•,�� pat heor toir overede,alsoretom an tno,imosu,for sucCharacter's
rileaeLaw(ned utemenl
FFxxO thuheuccenwdPurwanttetheofDivnuaton 3 of ft Bush.ammmmlow(Cmc)or Sq.Ft.Floor Area Vauauon
cdFs drat(cohi sexe pt t Stttfon romandqu Dasisfrh(tineged euand Profession Cmc)
tial he ts exempt uwrtfrom and sew basis for Ne alleged exemption.My violation of
Section 7031.5 by airy applicant for a permit anbjau the appileanl to a CIA penalty of 3 7p n;10 0 Occupancy Type
not more then Rw hundred dnflaa(SM
❑1,a owner o(dw property.or my employees with wages u their and compensation,
will do the work.and the suucwre is not intended aoffered(or soh(Ser.7011.Butims,
and Professions;Code:The Contractors License Law does nm apply w an comer of Required Inspections
property who nulldsorfmp nnou thereon,andwhodoessuch work himselfathrough Ms
own employees,provided Nat such Improwm rds sus not Intended ao0crtd for sale.If,
however,the building or Improvement is sold within one year of completion,the owner•
builder will have tho burden of proving that M did not build or improv for purpose of
sele.).
❑1.as owner of the property.am exclusively contracting with Headlund mnuacten be
counted the project(Sec.]041,Business and Professions Code:)The Comruwrs W-
muse law does not apply te an owner of progeny who builds or Improves tharea,and.
who contracts for such projects with a convict")licensed p rruenl w the Convenor's
License law.
❑I am exempt under Sea .B&P C for this reuan
Owner Dow
40 WORKERS COMPENSATION DECLARATION '
I hereby affhm under penury of perjury one of the following declamations;
I bus and will method.a CeNfieshe of Consent te self-bnure for Workee.Conches.
ssllon,as provided for by Section 37M of the Labor Code,for the performance of dw
work for which Nis Permit is Loved.
❑1 have and will maintain Workers Compensation Iuosnce,as required by Section
3700 of the labor Cade,for Law performance of the work for which this permit is Issued.
kµµ{ly Wo
rker,Computation Interum tinier and Policy number art:
C,mdr; SN\TL+r FC-C IC Policy NoAm C- '3 V TnS 7,mal -O
CERTIFICATE OF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE
(Thtsucllon had not bccamplesed if the permit Is forme hundred do hers($10n)
a less.)
I cenify that In the performance of the work for which this Permit is tssaed,I shall no
employ any person in any manner in as in become wbjecuo the Worken'Compcuadon
Laws of California.Dew
Applicant
NOTICE TO APPLICANT:IL alter making this Continents of Exemption,you should
become subjm,to the Woricui Compensation provisions of the labor Code,you mum
,J z foMwith comply with such provision or this permit Nall be dcemed rtwoke0.
'Z'55 CONSTRUCTION LENDING AGENCY
(.r Ihereby Affirm the,Nem is a construction lending agency for the perfurmarwc of
a ti IW work for which Nis permit Is issued(Ser.3097,Civ.C.)
W 0 Lenders Name
z Landers Addmu
IJQ IaNe that 1haw andthcty and
nmad yosaw that the sWwiw mmaungto
D. cuneus 1 omm ct comply with all city add county ucau.tes and eau lam relating w
LJ Wlldin4muoan
eon,and hereby authodw rePretenWiws afNtscity In enter upon now
W progeny fo wmpeetion purposes.
g1. e w sew,indemnify and keep harmless now City of Cupertino against
enu.comsandexpeues which may in anymymcme Mainsluld City
fNo toling afthis Permit. � O )NDERSTANDS AND WILL COMPLY WITH AIL NON-POINT Issued by:91ta� Date •! J JLATTONS. • I '6S
Re-roofs
signature ppdicanvConuacwr Dew
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will No applicant or factum building occupant slow or handle hevafdous mewdal
as defined by the Cupertino Municipal Code,Chapter 9.12.and now Health and Safely
Code.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes �La
Will the applicant or future Wilding occupant use equipment or dwims which If a roof is installed without first obtaining an inspection,I agree to remove
malt hazardous air mmamimmus u donned by the Bay Area Air Quality Management all new materials for inspection.
Wrict7
❑Yea
ate
Woodcuts materials requirememt under Chapter 6.95 ofdw Califor.
.is N e adc.S=.Um 25505.25533 wall 25534,1 undersuM that ifuw Wildint
does 1 c m ow a tehane Nm 1,w my mspomibility w nodfy now occupant mat Nc
myu me h mus t"mer pdorwissuaoceofaC nob Signature ofApplicant Date
owner ser authod a ant t' Dow
All roof coverings to be Class"B" or better