03080011 CITY OF CUPERTINO '�-�
as
Bu11.Dmc DlvlsloN PERMITCONTRACTOR INIaORMA ION
BUILDING ADDRESS: _ RUDOLPH & SLETTEN INC PERMIT N%3080011
sOWNERS NAME: 989 E HILLSDALE BLV PERMIT ISSUE DATE
Adih,HEWLETT PACKARD SANITARY NO, CONTROL NO.
\
NE: (415) 572-1919
ARCHITECT/ENGINEER: . BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
i o o LICENSED CONTRACTOR'S DECLARATION- Job Description
C 1 hcmby affirm that 1 am licensed under provisions of Chapter 9(commencing
b with Section 7000)of Division 3 of Ne Business and Professions Code,and my license is
mTullio and IficN i
e st te�Sote9
Limen ss Contractor
DEMO EXISTING SHEETROCK(LOADING DECK)
�Fp Dam nsr
ARCHITECTS DECLARATION
E 2 l understand my plana shall N used as public recnNs
you
soy Licensed Professional
g OWNER-BUILDER DECLARATION
IS 1 hereby affirm Nat I am exempt from the Contractor's License Law for the
p O following reams(Section 7(IJ LS,Business and Professions Codc:Any eitynr county
3 which requires a permit to construct alma improve,demolish,or repair any structure
¢i prnent
ioo as issuance,also inquires the applicant for such permit m rile a signed so no
a
that he is licensed pursural1.the pmvoinnsofd¢Contractor's License,Law(Chapms9 Sq. Ft. Floor Area Valuation -
rF❑`p (commencing wi@Section 7")Of Division 3 of the Businessand I'mr.osiona Code)or
i?3$ NN
at he is exempt warrom and the basis for Ne alleged exemption.Any violation of 31607046 . 00
Semon 7031.5 by any applicans for a permit subjects the epplaml loacivil penally of APN Number Occupancy Type
not more Nan five hundred callars(S500). - -
❑1,as owner of the property,or my employees with wages u their sole compensation,
will do the work,and theswcture is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's Liceose Law it=it=not apply m e an owner of q P
property who builds or improvesthemon,and who does such work himself er through his
ownemployecs,provided thasuch aramocencrosse not intended or offered formic.If,
however,the building or improvement is mid within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sam).
❑1,as owner of the progeny,am exclusively contracting with licensed contractors to
construct the pmjcct(Sec.7814,Business add Professions Code:)The Comm cmr's Li. �.
cense Law does not apply to an owner of property who Wilds or improves thereon,and
who contracts far such projects with a contractor(s)licensed pursuant to dm Contractors
License Law.
1 am exempt under See. B&P C for this recon /fes Jf
Owner Dam
WORKER'S COMPENSATION DECLARATION P/�
I hereby afOren under penalty of perjury one of the following declarations: /
I have and will maintain a Certificate of Consent to self-insure for Workers Compere
sation,as provided for by Section 37M of the labor Code,for the performance of the
work for which this permit is issued. Y
I have and will maintain Worker's Compensation Insurance,as required by Section -
3 of the Labor Code,for the performance of dm work for which this permit is issued. ,
My Workp�s's Cnmpen atipn Insurance carticr and Policy number am:
Cartier.f A � T*.Iicy Na: .
CE IFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not N completed if tN permit is for one hundreddidwo(SIM)
or less.)
1 ccnify Nat in the performance of the work for which this permit is mood,l shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Conificem of Exemption,you should
become subject m the Worker'a Compensation provisions of the Labor Cade,you mon
70 forthwith comply with such provisions or this permit shat l he deemed revoked.
ti tiCONSTRUCTION LENDING AGENCY
I hereby Orion that there is.conswctinn lending agency for the performance of
Y.> the work fur which this permit is ismad(Sec.3097.Civ.C.)
Yt7 Lender's Name ,
z Lcnder's Address
J O 1 certify Na,I have read this application and stem that the above information misting to
Ubuilder 1 agree m comply with all city and ceanty ordinances and Crete laws relating e
V Wildingeonswetion,and hereby awhonprposesematives of Ni¢City menmr upon the
a shove-(W)untol agree property for inspection an keep hs. .
(We)agree to save,and expenses
and keep harmless the City of against s against
Jll`b liabilitiesjudgmentsecraning grami ng of this esmit, may inany way acme against sold City
¢-" APPLICAin dNTeof UNDERSTANDSIA'ND WILL COMPLY WITH ALL NON-POINT Issued by:qjt(2� Date Ute`
SOURCE REGULATIONS.
Re-roofs
Signemrc of ApplicanO Dak
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or(mune building occupant nom or hazardous material
u defined by the Cupeninn Municipal Coda and th Chapter 9.I2,and the Health and Safety
ode.Section 25532(a)? �e All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hazardous air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
"In
[
❑Yes _
A01
howth zaNnus materials reyvimmdnts under Chapter 695 of Nc Califnr,
,Seed.¢25505.25533 and 25534.1 understand Nm if Bic Wilding
ve tenant, o yesponsbilay to nndfy the 11 l ofthe
mu the mete' anis anccofa Ccrtiricam of rant Signature of Applicant Date
y(da ant Date All roof coverings to be Class "B" or better
CITY OF CUPERTINO
DEMO o� 4 9- v d //
CUPEI�TINO PERMIT APPLICATION FORM
APN # 316 O"� 04 to Date: 8 If IQ S
Building Address: p
19111 P&-. E vbc.& A-4S, c,,,r7Etr�o CA 4(r•,y
Owner's Name: Phone#:
Contractor: 4 St
n License#:
'�v-4a�lE ..atTE.3 V 69
Contact: Phone#:
a.-CA g.-Qk& 403 2%o - 493(a
Applicant/Contractor: nn
Building Permit Info:
Bldg Elect Plumb Mech
Job Description: aJ, o Ea.,SsI Cj),%"CX-QAC.0 - CL°a,..,.a5 4 ST.q S-16-err
Residential: 14re b& Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
4 �Sao
Architect/Engineer: � '� Valuation: ee
IQ.
Type of Construction: Occupancy Group:
•
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
BSEISMICRE Seismic Residential BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG
2 � 70z
/ o7. s� ,