03100029 CITY OF CUPERTINO -^•s ' ` ° 'T°
BUILDING DIVISION PERMIT 'COIVTRACT(7R INF.4RMATIONa`>
BUILDING ADDRESS: RUDOLPH Sc SLETTEN INC PERMIT NOO 3100029
19111 PRUNERIDGE AVE # 44
WNER'S NAME: 989 E HILLSDALE BLV PERMIT ISSUE DATE
HEWLETT PACKARD 10/30/2003
E (415) 572-1919 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
X00 LICENSED CONTRACTORS DECLARATIO^ l, p 'WALE®
w❑ 1 hereby affirm that I am licensed under provision of Chapter 9(rommencin Job Deseri
t�W with Section 70IX1)nf Division Sof NCeusinrsx and Professions Codc.and myliccnw is
infnnmrceandeffect. CANOPY ADDITION (BLDG 44)
a�? License Class Lie.P
t ce Dale Contractor 70 SQ FT �I s/1
il� ATION
1 understand my ploon.tWll be ARCH todDas ruby.records NOV y 2004
ayU
CI-
y Licensed Professimol
OWNER-BUILDER DECLARATION BUILDING
a f 1 hereby affirm thatOW I am exempt from Ne DECLARATION
License Law for the
O O fullowing 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
3iy prior b)its issuance,also requires the applicant fursuch Permit u file a signed statement
that he is licensed pursuant to the previsions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valu4t165000.
` $ (commencing with Section 7")of Division 3 of the Business and Professions Code)or
that he is exempt therefrom and the basis for lie alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit ubjects lie applicant o a civil Penalty of
not more than five hundred dollar&(S500). -3 APN r U U Occupancy Type
❑I,as owner of the pmperty,or my employees with wages as their sole compensa0on,
will do the work,and the structure is not intended or offered for sale(Sec.7844,Business
and Professions Code:The Centimeters License Law dos not apply in an owner of Required Inspections
progeny who builds or improves thereon,and who does such work himselfor through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,lie owner,
builder will have Ne burden of proving that he did not build or improve for purpose of
sale.).
1.as owner of the property,am exclusively contracting with licensed contractors to
co was the project(Sec.]044,Business and Professions Cade:)The Conations Li.
come Law does not apply to an owner of property who builds or improves lhemon,and
who come&for such projects wit a eontraclons)licensed pursuant to the Contractor'&
License Law.
lam exempt ,Ste. B&PC for thus
on
❑ p
Date Q
WO KER'S COMPENSATION DGCI�!$yd1GN
1 hereby affirm under penally of perjury one of lie fallowing declinations:
❑this ve and will maintain a CeniOcara Of ConsenuO sel0sur
ine for Worker'scompen-
satic n,n provided for by Section 3000 of the labor Code,for the performance of the
work for which this Permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 Of the labor Code,for lie performance oldie work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is faronc hundred dollars($100)
or less.)
I certify toil in the performance of the work for which this permit is issued,1 shall not
employ any Person in any manner w as to hewmc subject to the Workeri Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should -
become subject to the Worker's Compensation provisions of the labor Codc,you must
Oforthwith comply with such provisions or this permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the Performance of
Ya > the work for which this permit is issued(See 3097,Civ.C.)
QLender's Name
D,Z Lender's Address
;J Q 1 certify that I have read this application and state that the above information is -
Fcorrect.1 agree to comply with all city and county ordinances and sate laws relming to
U building construction,and hereby authorize representatives Of this city to enter upon the
above-mentioned property for expenses
purposes.
ti d (We)agree to save,indemnify and keep harmless the City of Cupertino against
h liabilitiesucncc cn,cosaindexpenseswhich may in anyway ettrue against said City
Z inconwqAPPLICAeNTCUf DERSTANDSIAV WILL COMPLY WITH ALL NON-POINT Issued by: Datenj
SOURCE RE TIO
I.t na�pplica Contractor 101 Re-roofs
AZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant atom or handle hazardous material
as defined by the Corundum Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section zss3zwp
❑Yes All roofs shall be inspected prior to any roofing material being installed.
' �kuu
y the B / If a roof is installed without first obtaining an inspection,I a ree to remove
Will the applicant or future building equipment or devices which g „M
11 mit hexartlnus air contaminants as definedbby the Bayy A Arca Air Quality Management all new materials for inspection.
Di&men
Dyes ICI No
I have mad the haaardous materials requirements under Chapter 6.95 of the Califor-
niaHcaW&SafctyCWc,Sccuons25505,25533wd25534.1 undersand Nmifthc building
does not Fill h ve a anent,that it is my msponsihility m notify the rceupant of the
mquimm hi' must Ipno,to*...of.CcnificatcofOreopersy Signature of Applicant Date
ner or aulb ized agent tcI All roof coverings to be Class "B" or better