05020025 t
CITY OF CUPERTINO r ° f
BUILDING DIVISION
PERMIT CONTRACTAINOta
n$ss
BUILDING ADDRESS: RUDOLPH & SLETTEN INC PERMITN65020025
OWNER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY NO. CONTROL NO.
i
5
CHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a.lam1
LICENSED CONTRACTOR'S
OuR'S DECLARATION Job Descri ftioli,%.tf�l
(Y I hereby aGlt 1 un licensed under provisions of Chapter
r 9(commencingp U r
with Section 7M)of Divl,on 3 of the Busecu and profession,Cade,and my license is ✓ fi
in full force and t. dy
ro=z I Lk.« (two TI--HANDICAP WALKWAY ty 5, ;»
�g' Dam Contractor.
34� ARCHfrECTS DECLARATION -9r' �Yb
3�� I undcrmnd my Pkns shall h wetl as public mcmd,
Bo
/f _
7 Licensed Professional //`✓lh//Vn��
OWNER-BUILDER DECLARATION
i I hereby affirm that I am exempt from the Contractor's License Law for the n
p O fallowing mason.(Section 703 LS,Business and Professions Code:Any city or county
•ue.j$ which requires a permit to construct.alter.Improve,demolish.an repair any smaQure
FZ�' poor miss issusnec.atsu requires tiro aPPlicmtformch permitm Ole asi{ued wtemem w
FF <
think
ommencmnmd purmam mthe of
or theve Buecromand Prselaw(Clupter9 Sq.F[. Floor Area Valuation
C�m
(Commencing is
with Section 7080)of Division S olive egad ca,and on.My viCnde)or
$ Nat he ts ezempt dime(rom arM dte buss for the alleged ewnpttan.My violation of
Section 7031.3 by any applicmt for a permit subject,the applicant to a civil penalty of 3 L49NNdrA3e0 0 Occupancy
not mom man five hundred dollars($5M), p y��
❑I,as owner of the property,army employees with wage,u their mle compenadon,
will do the wick and thesuucture is notbmnded oraQered formic(See.70th,Business
and Profavmons Code:The Connector's Liame Law don not apply m an owner of Required Inspections
properly w ho builds m lmpmve Women,and who doss such work himsel f er through his
own employees,provided that such improvements an,but ImeMed oroRued fornk.If,
however,the building or improvement is sold within oro year of completion,the owner.
builder will have the human of proving Nat he did not build or Improve for purpose of
ole.).
❑1,as owner of the property,am exclusively contracting with licensed contractors in
construct tiro project(Sec.70th.Business and Professions Cade:)The Consecules Li.
cause Law dm not apply m an owner of property who builds or Improve desmon.W
who contracts for such projects with a conuatorts)licensed personal to the Contractor's
License law.
❑lamexemptunder Sea ,BkPCforthismxoo
Owner Date
WORKER'S COMPENSATIONDECLARATION -
1 hereby affirm under paonity of perjury oro of the following declarsdom:
ham and will maintain a Cuameme of Consent m self.imu a ran Worker's Compen.
as provided for by Section 3700 of Ne Labor Code.fm the performanx of the
Islift for which this permit Is issued.
❑I have and will maintain Worker's Compensation Insurance,an required by Section
3700 of the Labor Code.for Om pciformance of the work for which this permit is issued. -
\ My Worker's CampewNanylasmnnce caner and Policy number am:
Ca�r..P4(m ern 14 1 policy No,W(-3ql �
CERTIFICATE OF EXEMPTION FROM WORKERS'
p' COMPENSATION INSURANCE
(Thi,eecdan need rimbecompleted lithe permit is fmowhundmd dollars($100)
or less.)
1 certify that in the performance of the work for which this permit is hued.I shaft not
employ any person in any manner m u to become subject in ger Workers'Compemadon
Law.of Califomie.Data
Applicant .
NOTICE TO APPLICANT:IL after making this Cer ifnum of Eamption,you should
become subject to the Worker's Compensation provision of the labor Cotler,you mum
,J O forthwith comply with such provisions or this Permit shall M deemed revoked.
„zCONSTRUCTION LENDING AGENCY
t" I hereby affirm diet Ommka commrctirm kMing agency for the wrrarmanceaf
fY.7., the work for which this permit in issued(Sec.3097.Civ.C.)
aQ Lender',Name
z Lender'sAddress,
V 0 1 certify that I have mad this application mil use,that the whom information la
WL:'! corcct.I A&=to comply with all city and county ordinances and sum laws relating to
0 rV' building construction,and hereby audience representatives of uiwity to enter upon Ole
{37 above-menfioned property fon impecd M.-S.
(\V)ag mum,indent Y PLP humkss the City of Cuperdno against
won y Ilabilida, d6 a ts.cmo codes which may in anywayammagaiwssid City
U7 In nc theg ting of permit.
IC DER ANDS D WILL COMPLY WITH LL ON-POINT Issued by:9102� Date
C E A ( wJ
W Re-roofs
8spiu ofA AZARDO TERIALSDISCLOSURE Date Type of Roof
Will the applcmt mfutum bu in{aceupanlmom or handle hevudoes material
as defined by the Cupertino Municipal Code,Chapter 9.11,and the Hcsidi and Safety
GWC,Section 135314)7
❑Yes `��
L�{u All roofs shall be inspected prior to any roofing material being installed.
Will the applicant in future building occupant use equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
t It lard, air can
tictomo a dcftncd by Om gay Area Air Quality Mmagement all new materials for inspection.
@
❑Yes �u
Ibveafe sic ,Sec6.mamnal.mquiwdZ53.1u"c pmt thaiftue Gilding
ala Hml &Safe t Ie.Section,153113, myrmd1333iylo o y anceenthe building
dos t c m h c i tenant that It i ser nee ale Ccrti w nnu'fy Om uecu�{nt of sic
req msec J i umhemmpriormissumceofaCadOc 19ctFyt Signature of Applicant Date
\, Ownerunu ar gent tis IOD{Jm All roof coverings to be Class"B"or better