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CITY OF CUPERTINO
BUILDING DIVISION PERMIT `+rr,w,
BUILDING ADDRESS:
RUDOLPH &
SLETTEN INC
PERMIT NOb 3 0 6 0 0 9 5
OWNER'S NAME:
989 E HILLSDALE BLV
PERM1rIss
06�
12/2003
H
PHONE.
( 415) 572 —1919
SANITARY NO. CONTROL NO.
ARCHITEC VENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a 0 a a
LICENSED CONTRACTOR'S DECLARATION
I Chapter 9
Job Description
hereby affirm that 1 am licensed u,pdcr provisions of (commencing
With Section 7 of Division 3 of the B *css and Professions Code, and my license is
in full force an freer. / y�
License CI Lic. k `---'���
.)TENANT IMPROVEMENT
V
_
Dale—q - _. "• Contracto-
HITECi'ARATIONA
understand my plans shall be usal public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 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 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
Sq. Ft. Floor Area
$150)6 tion
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and time basis for the alleged exemption. Any violation of
3 7P�$i1i>�@r0 0
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars ($500).
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
101
-UNDAk jjaq
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
d Inspections
property who builds or improves thereon, and who does such work himself or through his
10 2
— PIERS
own employees, provided that such improvements are not intended or offered for sale. If,
103
— OF ER
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
104
- REBAR
sale.).
10 5
— ANCHOR DOLTS
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. law, Business and Professions Cade:) The Contractor's Li-
106
— SEWER & WATER
cense Law does not apply to an owner of property who builds or improves thereon, and
202
- UNDERFLOOR PLUMBING
who contracts for such projects with a contmctor(s) licensed pursuant to the Contractofs
License Law.
203
- UNDERFLOOR MECHANICAL
E]1 am exempt under Sec. , B & P C for this reason
204
- UNDERFLOOR FRAME
Owner Date
WORKER'S COMPENSATION DECLARATION
205
- UNDERFLOOR INSULATION
I hereby affirm under penalty of perjury one of the following declarations:
301
— ROUGH PLUMBING
0 haw and will maintain a Certificate of Consent to self -insure for Worker'sCompen-
302
— TUB & OR SHOWER
salon, as provided for by Section 3700 of the Labor Code, for the performance of the
303
— ROUGH MECHANICAL
work for which this permit is issued.
304
— ROUGH ELECTRICAL
I have and will maintain Worker's Compensation Insurance, as required by Section
issued.
3 05
— FRAME
3700 of the Labor Code, for the performance of the work for which this permit is
My Wo ker's Compensation Insurance carrier and P(Acy number am:
Lt 34y��3<'
306
— HOLDOWN S
hjG
CERTIFICATE OF EXEMPTION FROM WORKERS'
307
- INSULATION
COMPENSATION INSURANCE
308
- SHEETROCK
(fhissection need not becompleted ifthepermit isforonehundred dollars ($100)
309
— EXTERIOR LATH
less•)
310
— INTERIOR LATH
II 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
311
- SCRATCH COAT
Laws of California. Date
Applicant
313
501
- ROOF NAIL
- F I NAL ELECTRICAL ENERGY
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
forthwith comply with such provisions or this permit shall be deemed revoked.
502
— F I NAL PLUMBING ENERGY
CONSTRUCTION LENDING AGENCY
503
- FINAL MECHANICAL ENERGY
I hereby affirm that there is a construction lending agency for the performance of
504
- FINAL BUILDING ENERGY
the work for which this permit is issued (Sec. 3097, Civ. C.)
Leder's Name
n
505
506
- F I NAL ELECTRICAL
— GAS TEST
Lender's Address
i I certify that I have read this application and state that the above information is
- FINAL PLUMBING--
' correct. I agree to comply with all city and county ordinances and state laws relating to
construction.507
building construction. and hereby authorize representatives of this city to enter upon theF
I NA ME CHAN CAL
above-mentioned property for inspection purposes.
0 9
FIN
(Wc) agree to save, indemnify and keep harmless the City of Cupertino against
j liabilities, judgments, costs and expenses which may in any way accrue against said City
5
G-+
' in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WIT y ALL NON -POINT
Issued by:51
dr
WORKS Date
SOURCE REGULATI //
"Y
-6 C f;4
Re -roofs
Type of Roof
ignature of Aplin cant/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)7
All roofs shall be
inspected prior to any roofing material being installed.
❑ Yes
�o
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?
❑ YesNo
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 is my responsibility to notify the a:cupant of the
req cm/c�� wIt It must be et prior to issuance of a Certificate of 0, cu r•
W''iRR
Signature of Applicant Date
CCiYL1 ( %
All roof coverings to be Class " 13 or better
Owner or authori agent Date