07020022CITY OF CUPERTINO
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BUILDING DIVISION PERYW
BUIL I G D ESS:
D1?M
PERMIT NO.
PRUNERIDGE AVE #44
RUDOLPH & SLETTEN INC
07020022
OWNER'S NAME:
PERMIT ISSUE DATE
.HEWLETT PACKARD
1600 SEAPORT BLVD
PHONE:
SANITARY NO. CONTROL NO.
(650)216-3643
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000)ofDi�.dpn3oftheBusinessandProfessi nsCode. and mylicense is
B44 PHASE 3 CORE & ADA COMPLIANCE UPGRADES
in full force and effect�iL/ /_
License C s Lic. N �
1
Date Contractor
T
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior a) its issuance, also requires the applicant for such permit to file a signed statement
he is licensed to the of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that pursuant previsions
(commencing with Section 7000) of Division 3 of the Busincsssand Professions Cock) or
$7 0 0 0 0
that be is exempt thctcfrom and the basis for the alleged exemption. Any violation of
Number
W
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (ZW0
31607044
i, as owner of the property, or my employees with wages as them sole compensation,
Required Inspections
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will do the work, and the structure is not intended or offered forsale (Sec. 7044, Business
and Professions Code: The ContractorLicense Law dots not apply to an owner of
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property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 70", Business and Professions Cafe:) The Contractor's Li-
cense law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a contractor(s).licensed pursuant to the Contractor's
License Law.
0 1 am exempt under Sec. , B & P C for this reason
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
0 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
. .
work for which this permit is issued,
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
'
My We s Compensit on I urance carrier and Policy umb r are:
Cartier. olicy o.:
�J
d Q
CERT1FICA OF FXEMPTION FROM WORKERS'
I
COMPENSATION INSURANCE
(Phis section need not be completed if the permit Is for one hundred dollars ($I00)
or less.)
I ceri[y that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manncrso as to become subject to the Workcri Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
s forthwith comply with such provisions or this permit shall be deemed revoked.
y CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit Is issued (Sec. 3097. Civ. C.)
'
Lender's Name
L.cnder's Address
I certify that I have read this application and state that the above information is
correcL I agree to comply with all city and county ordinances and state laws relating to
Jbuilding construction. and hereby authorize 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
n liabilities, judgments, costs and expenses which may In any way accrue against said City
7 in consegrrcncc of the granting of this permit.
"' A ICANT UNDER ANDS AND WILL OMPLY WITH ALL N N-POINT
Issued by: Date
S CE U
S {'
Re -roofs
Type of Roof
Signature of Applican ontractor Datc
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes �
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes �fVo
1 have "cad the hazardous materials requirements under Chapter 6.95 o[thc Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534. I undcrsmd that if the building
oes not curenrly have a tenant. that it is my responsibility to notjfy the occupant of the
ircm ts which be m l prior to issu of a'�pprtificatoof Occu ,
Signature of Applicant Date
.f,
� All roof coverings to be Class "B" or better
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Owner or authorized agent 1 Du