03120098 CITY OF CUPEIITINO "'"
BUILDINGDIVISION PERMIT CONTRACTORNFbAMATI�O'' N
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BUILDING ADDRESS: RUDOLPH & SLETTEN INC PERMITNO.0.3120098
OWNER'S NAME: PERMIT ISSUE DATE
HEWLETT PA
E: SANITARY N0. CONTROL NO.
(415) 572-1919
ARCHTTECTIENGINEER
15 572-
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LOO
LICENSED CONTRACTOR'S DECLARATION
F 1 hereby storm Ihnl am licensed under provisions ofs Code, 9(commencing Job DBSCiIptlOn -
`uj
with llfronndefecDivisioni ofthc Business and Pmfessiuns Cole,and mylicenu is
n in full force and effect.
License Class - Lic.N TI--GLAZING TO COMP : R00'}oAIj-,M
n�p Dam Omiounter r�PJAs LE0
¢ ARCHITECTS DECLARATION
8 I understand my plans shall be..it as Public records
6°
Is Licensed Professional FEB 2 5 2004
S - OWNER-BUILDER DECLARATION
eq 1 herebymasa affirm that 11. exempt from the Contractor's Co :Any c Lew fur the
K02 following mason.(Semon Tf13 construct.5,Business antl Professions Cole:Any city Os county SPUN
m- which its abs a paumit murrestaalter,improve.demolish.au repair any stricture
'tZQ pat the incensed pursuamgt)the the for such Conararmi0o fila asigned aw(Chapter
mmmcm
�p irnno
in mencing licensed pursuant it)theof theeBuscess anccnufaw(C Code)
Sq.Ft. Floor Area Valuation
in with Section]WO)of Division J of the Business and Professions Cai1c7 tar
5 S Nat he is exempt memfrom and the basis for the alleged exemption.Any violation of t anC
Section 7031.5 by any applicant for a permit subjects N10e applicant a civil penalty of 3MN'I'•n ilibeT00 Occupancy Type
net more man five hundred dollars(i Cth. P y YP
1,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the swctum is not impended or.ffC.d fonalc(Sec.7094,Business
and Professions Code:The Contractor's License Law docs not apply to an owner of Required Inspections
pmpeny who builds or improves thereon.and who domsuch work himself m through his
own employcas,provided that such improvements are not intended oroRered for sale.IL
however,the building or improvement is aold within one year of completion,the Owner,
builder will have the burden or proving mat he did not build or Improve far purpox of ,
oIt,), .
1,a owner of fee property,am exclusively contracting with licensed contractors to
.. Ci the pmject(Sec.7044.Business and Professions Cade:)The Contractor's Li.
cause law does not apply in an owner of property who builds or improves themon,and -
who tantrums for such projects with a contractors)Licensed pursuant to the Commelor's
License Law. - -
V1w
In uederS ,B&P C for this mmnn
s t/L— qam
RKER'S COMPENSATION DEC ,LAI R�'fa
y allure under petrify of perjury ane of the mg declarations:
will maintain a Certificate of Consen0o self-insure for Worker's Compere
salon,as provided for by Section 3700 of the Labor Coca.for the per(ormaMe of the
work for which this permit is island.
❑I have and will maintain Worker's Compensation Insurance,m required by Section
3700 or the Labor Code,for the performance of the work for which this permit is bound.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Qhlssectionneetl not bO completed hills,famnit is fnronehundred dnllns(SIM)
nr lass.)
1 certify that in the performence of the work for which this permit is found.l shall nes
employ any poison in any mannerm m to hecome subject to the Workers'Compensation
Laws of California.Dem
Applicant
NOTICE TO APPLICANT:IL after making this Cenificam of Exemption,you should
became subject to the Worker's Compensation previsions of the labor Code,you man
,JO
Eit forthwi th comply with such provisions or this permit shall be deemed ranked.
Z CONSTRUCTION LENDING AGENCY
(—'ti I hereby affirm that them is a Construction lending agency l'or the performance of
the work for which this permit is issued(Sec.303E Civ.C.)
W�Q Undoes Name
Z Lender's Add..
U Q 1 certify that 1 have read this applicaion end into that the those information is
fL F cornett.I agree m comply with all city and county oNinmcea and slate lewa relating to
C) building construction.and hereby amomire rapnummalives of join city to tour Uom the
Uabove-mcmioned properly for inspection Purpoxs.
(We)agme m rave,indemnify and keep harmless the City of Cupertino against
rFi IA liabilities,judgments.costs and expenses which may in any way same against said City
V Z in consequence of me granting of this permit.
" APPLIC NDERST DS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU`E fE AT1QN L— Iry 9/O�
f fA. �1\ Re-roofs
Sign fAppbcan on rector r Dem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant Municipal
odeee haul r9.12.handle Health us and Safety al
m defined by me Cupertino Municipal Code.Chapter 9.13,and the Health and Safely
Cade,section 2553R.)7 All roofs shall be inspected prior to any roofing material being installed.
' ❑rax ` 4a
Will the applicant or future building attupanl use mind or devices which If a roof is installed without first obtaining an inspection,I agree to remove
herardous air contaminants m defined by the Bay Arca Air Quality Management all new materials for inspection.
❑Yes XNu
I have mad the traitorous materials rcquimments under Chapmr 6.95 of the Calif.,
nit Health&Safety Code.Scclimu 25505,25537 and 25534.1 understand that if the building
dX�p
that it a my respomihility m and ly the necuprim of the
prior1.issuanceofaCCNftccionofOccup my. Signature of Applicant Date
I` Data All roof coverings to be Class"B"or better _