06120021 CITY OF CUPERTINO
BUILDING DIVISION HERMIT C� �GC1R I�tE� ZMTICIN:
BUILDING ADDRESS: PERMIT NO.
19111 PRUNERIDGE AV RUDOLPH & SLETTEN INC 06120021
n"rNER'S NAME: PERMIT ISSUE DATE
IEWLETT-PACKARD 1600 SEAP
NivNE: SANITARY NO. CONTROL NO.
(650) 216-3643
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
i 0 O LICENSED CONTRACTOR'S DECLARATION
uI hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
z with Section 7000)of Division 3 of the Business and Professions Code,and my license is
<N in full force UPGRADE STAIR AND 24 TOILET ROOMS FOR TITLE 24
and of t 1 V O6_+
,�z LicenscClass Lic.lf s CONFORMANCE ON 1ST, 2ND, 3RD FLOORS OF BLDG 44
3 t— Date--3-- .n» Contractor
Lu ARCHITECTS DECLARATION
i C< I understand my plans shall be used as public records
2 U
o H Licensed Professional
y< OWNER-BUILDER DECLARATION
a 1 hereby affirm that I am exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
`< [y i which requires a permit to construct,alter,improve,demolish,or repair any structure
Z
In prior to its issuance,also requires the applicant for such permit to file a signed statement
_`e that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
i H (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $1500000
i r3 that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of ANumber Occupancy Type
not more than rive hundred dollars($500). 31607042
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's Licemic Law does not apply to an owner of q P
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.7044,Business and Professions Code:)The Contractor's Li-
ccnse 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.
❑1 am exempt under Sec. .B&P C for this reason -
nerDate
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I 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 Worker's Compensation Insurance carrier andPolicynumber are:
Carrier.Ztiei(,� �4A IIM�olityNo.7
W[.3+/QS3o7o7
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for anc hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to become subject to the Workers'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
O forthwith comply with such provisions or this permit shall be deemed revoked.
z" CONSTRUCTION LENDING AGENCY
Fr 1 hereby affirm that there is a construction lending agency for the performance of
lx> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q
Lender's Name
Lender's Address
U 0 I certify that I have read this application and state that the above information is
LL
0' correct.I agree to comply with all city and county ordinances and state laws relating to
v v building construction,and hereby authorise representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
,may liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREGULA
4�1
T_V Re-roofs
Signa re of pplicaratCon r Date
HAZXRDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
az defined by the Cupertino Municipal Codc,Chapter 9.12,and the Health and Safety
ode,Section 25532(a)? All roofs:hall be inspected prior to any roofing material being installed.
C]Yes o
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new m lterials for inspection.
District?
❑Yes �flo
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building
does not currently have a tenant,that it i y responsibility to notify the occupant of the
requirements ch t of a Certificate of Occupancy. Signature of Applicant Date
Owner or authorircd agent Date - All roof coverings to be Class"B"or better