01050167CITY OF CUPERTINO
BUILDING DIVISION
PERMIT
BUILDING ADDRESS:
19091 PRUNERIDGE AV BG4
CONTRACTOR INFORMATION:
RUDOL.PH & 51-_ETTEN
PERMIT NO.
I OWNER'S NAME: APPLICATION SUB DATE 1
HEWLETT—PACKARD 989 E HII.-I CDAt E BI. -1 05/22/ 001 �
PHONE: y, SANITARY NO. CONTROL NO.
(4-15)57
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Co e, a= m licen
in full force and effect. -
enseclass Lic.# f EMPORAf:%Y PERM.I T ONLY/
VALID FOR 30
e Contracto
ARCHITECT'S DEC ON
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I 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 to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code)
or 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 not more than five hundred dollars ($500).
❑ 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 and Professions Code: The Contractor's License Law does not apply to an
owner of 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.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's
License 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
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker's
Compensation, 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
jssued. My Workers Compensation Insurance carrier and Policy number are:
Policy No.:
[TION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
I(This section need not be completed if the permit is for one hundred dollars
($100)orless.)
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
0 forthwith comply with such provisions or this permit shall be deemed revoked.
�.
V�J CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance
W of the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Z Lender's Address
V I certify that I have read this application and state that the above information is
W (~ correct. I agree to comply with all city and county ordinances and state laws relating
V to building construction, and hereby authorize representatives of this city to enter upon
(� the above-mentioned property for inspection purposes.
a (We) agree to save, indemnify and keep harmless the City of Cupertino against
►w Z liabilities, judgments, costs and expenses which may in any way accrue against said
V City in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
OURCE REGULATIONS.
ature of Applicam/Contractor Date
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 ❑ No
1. 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
District?
❑ Yes ❑ No
I have read the hazardous materials requirements under Chapter 6.95 of the
'alifornia Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
the building does not currently have a tenant, that it is my responsibility to notify the
,upant of the requirements which must be met prior to issuance of a Certificate of
upancy.
or authorized agent
Date
or� Per0]rit
Issued prior to plan check
On Occupancy
Permit gq r Tit
From._.,
'FRC
Signatur
F' if '�WA T"Ef?
NG N
0171'
-- UNDERFLOOR MECHANICAL, ,4
204
— UNDERFLOORFRAME,
205
- 1.1t'3DE:RFLOOR T NSULAT ON --
301
-- ROUGH PLUMBING
.70,7-,
- TI -IR R- nR FHni-i -k
303
— ROUGH MECHANICAL
- ROUGH ELECTRICAL
Issued by:
305, • FRAME
_706 -- HOI._. DC Wtk-'I
-07 - INSULATION
:GHEE TRI_-ICFi
- EXTERIOR LATH
1.0 .
I N I E ION L.�4'1'H
6CRATCH COOT
1�17- fdnnF t.IP T I
x1719
,3
31.1
501.
502
571.3
504
505
A v e,
•- 1=' T #JAL_ FL FCTR I CAI_. ENERGY
-- FINAL PLUMBING ENERGY
FINAL MECHANICAL ENE=RGY
- F T NAL. BUILDING E:NF: ROY
- FINAL ELECTRICAL f_/1
GAS I L cs..f_ ✓ L
Date
Re -roofs 5t7)41 f T tlA!_ MF1::i-ft= N I f -,P1_
Type of Roof 5(19 FINAL GRADE.
510 FINAL PL.ANr TNG
All roofs shall br_ inspected prj� to any, roofing material being installed.
If a roof is inst@tle withwt-fi "obtaatlmyti..:g-,*Hnsokt—iBt1 I agree to remove
all new materials for inspection. Applicant understands and will comply with
all non -point source regulations.
Signature of Applicant Date
All roof coverings to be Class `B" or better
OFFICE