05040071 CITY OF CUPERTINO y ?Tuxiw�«f 1 Hit air ,eF; ,es, .Ax
BUILDING DIVISION PERMIT ;'CONTRACT,�OR TNFORMATI(?N.
BuaolNC ADDRESS: RUDOLPH &g SLETTEN INC PERMIT NO. 5040071
OW NER'S NAME: PERMIT ISSUE DATE
cI
E SANITARY OL NO.
ARCHEECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMS MECH
30o LICENSED CONRACTOR'SDECLARATION
'I 1 hereby affirm that 1 am licensed under prommons of Chapter 9(commencing Job Description
wilt do.7")ofDinWan3ofthc Butineuand ProfessionsCa9 andetyliceveu
in to 11 fora a�W({yQQQea�q�� q��b`
SKINS
License Lic.N DEMO BLDG. #41/CLOSE UP #42 &
Date i�3.��Gmmranar C
ARCHITECT DECLARATION LINK
1 undetatanJ my plans shall he used as public records
0 Licensed Professional
OWNER-BUILDER DECLARATION
I.a gp 1 heathy affirm Not I Ise exempt form the Con ons Co License Law for tM
p O following moon.permit
t ]construct,
Business and Priimprove.
am Cade:Any city or county
I.
$ which requires a lermit re conswc4 alms Im)wR,hpermitdemolish, file
epsigmy ned statement.'��� ' prior anic itsissuance.pualmrsuant
tM applicant for Courawit toiecue Law(Chapt em `',,1''
< that(commencing
Purwamrothe of Division 3 dtehe BuanM4 iavelaonsCoctn9 Sq.Ft.Floor Area �wys�tlOD000
zC� that he Is s unip, Sectionin and dice
Division(a the
the egad euand Pnoon.AnynnaCMe)or 'a a• V U
3$ Net he h eumpt dterefrom and Ne baso fm tits allegW exemption.Any violation of
Section 7031.5 by any applicant fora permit subject,the spplinnt W a civil penalty of APN Number Occupancy Type
not mom Nan five hundred dollars(5300). -
❑I,ummofdapmpeny.armyemployenwwwaguullnbwlecompemdon, 31607034 . 00
willdo thewon.and thesaunum Is notinunded oroQered for Ne(Sec.7014,Busima
ted Profeulans Cads:The Contractor's License Law don not apply m an own of Required Inspections ..
property who builds or improv thereon,and who dao such work himself or through his
own employes,provided that such Improvement,are not intended urortemal foraale.If.
however,Ne building or Improvement is veld within one year of completion.the owner.
builder will haw the burden of proving that K did nm build or improve for purpose of
etc.).
❑1,as owner of the property,am reclusively mnuactin{with licensed contraemrs W
contemner the pmjem(Sec.]ON,Busirom and Pmfesdans Code:)The Contractors Lt.
cense Law dm not apply to an owner of property who builds or improve themon.and,
who tomato for such pwjems with a commemr(O licensed purmant W the Contractors
License Law.
❑lameemptummo Sec. •B&PCfarthlsmuon -- • •�0
Owner DIte
SAT
WORKERS COMPENSATION DECLARATION _
1 hereby aM m under penalty,of perjury ane of the following dcelandons: V�ri�My
haw end will maintain•CeNBnteaf Conant to self-Insure for Woreers Compan.
etlan, profor mSection 3]00 of the labor Code.for theparfowaace of the
work(orr whichh this permit Is ivied.
Woave and will maintain Workers Compensation Insurance.as requited by Section
f the labor Code,for due perfarmatce of the wart far which Nu permit is Issued.
My Workers Cam enseuon Insurance nnier etW Polity num yens ,yq e
Canter: Polity No.: t� '�`f tJ
CERfIFlCA •OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
CNN sMlm reed not bccomplced lithe pewit is forme hundred dollara(5100)
N ksL)
I unify 041 in the performance of the work for which this pewit is issued.I slWl not
employ any perwn in my manner an as W bcmmc subject to the Worleri Compcnsadon
Lew.of California.Dau
Applicant
NOTICE TO APPLICANT.If.after making this CertiRnu of Exemption.you Amid
become subject W the Worker'.Compensation provisions of the lahm Codo,you mum
,J O forthwith comply with such provisions or this permluhall be dcemed reviled.
z CONSTRUCTION LENDING AGENCY
F+ IhembY lRnm Nat there is a mmwctinn lending agercy for die perform..or
G'i7 the were for which this permit 1.issued(Sec.3097.Co.C.)
ALenders Name
z Lenders Address
U Q 1 certify that 1 have mad this application and sate that the above information is
L,,;! COMCL 1 agree to comply with all city and county ordinances and suis laws mladng to
O`rJ' bulldingconswe' n and hereby authodm representatives of this city m enter upon the
{21 'hove-mentions ny forimpecdon purposes.
(We)ag save.indemnify ted keep harmless the City of Cupertino against
rjj lismiitiu,judg .cost,mdexpcns whichmayin anywayuc gaiml said City
U 7 In C.n gsee e f c granting of this permit.
APPCIeA ERSTANDS AND WILL COMPLY WITH LL N NPONT Issued by: Date
S RCE ONS.
to Re-roofs
ureo Applic tncontracturate
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building acupantstem or handle haeNous material
as defined by the Cupi nina Municipal Cade,Chapter 9.12.and the Health and Safety
Cade.Secdon25532(a)] All roofs shall be inspected prior to any roofing material being installed.
❑Yes ip(wo
Will the applicant or future building occupam one,equipment or denim which If a roof is installed without first obtaining an inspection,I agree to remove
baurdnu air ci nummanu as dcMcd by the Bay Area Air Quality Management - all new materials for inspection.
*. Lhchmaa
i ?
Nu
ousmaurialsmquimmenuunderCWpurA95oftheClifor-
5acdw23303.y5533vW2353a.TundcnundthetfdeWilding
unanL Nat It u my responsibility notify c occupant Of the
be met prior Wiumance.f.0 ,Icor c ane Signature of Applicant Date
Owner or mut Oapent / 0 Date All roof coverings to be Class"Bii or better