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CITY OF CUPEWFINO
BUILDING DIVISION PERMIT
;.,CONTRACT0RJNF RMATF IO. N qM
BU,LDINGADDRESS:
RUDOLPH & SLETTEN INC
PERMITNcb4040173
OWNER'S NAME:
PERMIT ISSUE DATE
HP
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SANITARY N0, CONTROL NO.
(415)572-1919
ARCI IM-Cr/ENGINEER:
BUILDING PERMIT INFO
BLDGELECT' PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
I heathy Affirm the, I am licensed under previsions of Chapter, 9 (commencing
p
with Section 7WX of Division 3 of the Business and Professions Code, and my license is
,A full tortes W.'r. t S0
License x �_ Lic, p
TI -REPLACE COOLING TOWER &
ASSOC. SYSTEMS
Dam CmuMChO U DOZ
ARCHITECT'S DE LARATION
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OWNER BUILDER DECLARATION
I hereby affirm that 1 nm mempt from the Contractors License Law for the
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Following reason. (Section 703 1.5, Business and Professions Code: Any or, or county
which requires a permit to construct. eller. improve, demolish, or repair any structure
prior 11) its Issuance. also requires the applicant for such parcel 110 IIIc a¢�I 9gd$181eme01
that he is licensed pursuant to the privi9lnnsof Nr. ryrygqccrori l/t¢nEliwiChaptnY
I
Sq. Ft Floo Area
V"tEo.A000
(commencing with Section 7000) of Dirk n the0bs CAAAdProfessions Clme)11(
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that he is eacmpl therefrom and due lud Poi the aIlc,,d exenipiiun.'Any violaliun'uf
1 —/
AP Iq4 111�7naasEr
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the ipplucant to a civil penalty of
not more Nan rive hundred dollars (SSW), 1¢t� ( I I
1. .
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1. As Acs of the Propcny, or my cmpl ea with wageY4 Nr.\ sol ampcnaetio ,l
will do the work, and dueatruclurt 1, 1, domffertdl sej�q(�ec. Rusin
and Professions Code: The Conmcmts LY qy trot a}ply4 an owner of
Required Inspections
property who builds or improves thereon, an work hi..Ifur through his
awn employ.., provided that such improvements tie or intended or f,.d for sale, If.
however. Ne building or improvement is sold within one you of completion, the owner
builder will have the burden of proving that he did not Wild or improve for purpose of
sale.).
❑ 1, as owner of Ne property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business end Pmfessions Code:) The Cwtracmr's Li.
cense law docs not apply to an owner of property who Wiltls or improves Ihemon, and,
who contracts for such projects with a conuactor(s) licensed pursuant he the Contractor's
Ciccone Law.
❑ l am Caere In under Sec, ,B&PC for this moon
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Owner Dem
WORKER'S COMPENSATION DECLARATION
-
1 hereby same under penally of perjury one, of the following dederations:
ase and will maintain a Cenifcate, of Consent to self-Insum for Worker's Comere
p
ton, as provided for by Section 3700 of the Labor Code• for the performance of the
wok for which this permil is issued.
_
I have end will maintain Worker's Compensation insurance, m required by Section
,
31 of the labor Code, for Ne performance of the work for which this permit is issued.
My WnrkAeri- C.n^mpe'n.w'linAn Insurance comics and Policy number em:
Co. �1CAA/ eA Policy N., W C5 995?
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WWW' nCGR'i1FJ�CATE I iXEICIPrION FROM WORKERS'
,_SCG
COMPENSATION INSURANCE
This section need not be completed lithe Permit Is for one hundred dollars ($100)
Or IcssJ
I cenify that in the performanec of the work for which this permit is issued, l shall not
employ any pamn in any manner an w at become subject to the Workers Compensation
'
Laws of California. Date
Applicant
NOTICE TO APPLICANT: IL after making his Cenincam of Exemption, you should
become subject to the Worker's Compensation provisions of the Iabnr Code, you must
forthwith comply with such provisions or this Permit shall Er. doomed mwked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that Vert its construction lending agency for she performance of
the work for which this permit Ia issued (Sec. A197, Civ. C.)
Landers Nome
Lenders Addreas
I cannily that 1 have read this application and ruse that the above information is
comet, 1 agree to comply with all city and county ordinances and au¢ laws relating to
building Construction. and hereby mthurim reposenmlives of this city to enter upon the
abovcmemioned properly for impection purposes.
(We) agree to save, indemnify and keep harmless the City or Cupertino against
liabilities. judgments. costs and eapenses which may In any way accent against said City
in consequence of the griming of this permit.
APPLI ANTUNOERSTSA(TNOAND WITH ALLfN-P01/f
Issued by: Date
.
L7/6
CNPLY
/S
Re -roofs
Signaturea'ApplicasyCommClor Date
— HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building oecupanl store or handle hazardous material
as defined by the Cupeninn Municipal Code, Chapter 9.13, and the HCallh and Safety
ale, sectien zss3zla)?n
❑ Yes
All roofs shall be inspected prior to any roofing material being installed.
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
hazardous air contaminants u defined by the Bay Area Air Quality Management
all new materials for inspection.
ice?
0 Y0 "KNo
I have read the hmardousmamrials requirements under Chapmr6.95 of the Caliror.
A ae Health &Safely Code, 9Ccumo 85(15,15533 and 25534.1 un@rsmnd Ihaif the Wilding
d¢x not currently have a tenant, dust it is my rtapotuibiliry no the necupant of Ne
re whifIt bemClpdorl lalm aCAM I:agof mpaney.
Signature of Applicant Date
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All roof coverings to be Class °B" or better
Ownc rain eel m