06100104 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ,CLINTRA.GTOR INFORMATION
BUILDINOADDRESS: RUDOLPH & SLETTEN INC PERMRNO.06100104
19111 P ETDGE AVE
OWNER'SNAME: PERMIT L'SUE DATE
HEWLETT-PACKARD 1600 SEAPORT BL 2006
E:
SANITARY NO. CONTROL NO.
(650) 216-3643
ARCHTIECf/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB . MECH
0 0 0 0
ipp LICENSED CONTRACTOR'S DECLARATION JOb Description
%wF I hcmby affirm Net l aro licensed under provisions of Chapter 9(commencing
:as with Section 70f10)inDivision 3 oftw Busincu aM PraessiameaCe.and my decade us
+�F infuRfume and cnm g 0� DEMONSTRATION HOME, , MODULAR STRUCTURE PER HUD
'�: tae"•"am Lla." STANDARDS (FOUNDATION & LANDSCAPE ONLY)
p Dem Contrr
:� actoARCHITECTS DECLARATION NO ADDITIONAL SANITARY CONDITIONS
i < 1 understand my plans shall he used an public ueords
a.lyU
o Licensed Pmfcssional
OWNER-BUILDER DECLARATION
f 1 hereby.Sero the I em exempt from the Gtinlmedar's License Law far the
a O following urian.Permit
t 103 1.5,Buiness and w,dei oro CWc:Any oily or county
m which iq i su a permit sa cnnstuch alke impose,demolish,me a sir any uumuu
-i< Priors issiensedpslu ugoires theappin Or me suchpermidw0laasiga (Chap em
s
that heentingsedpurwanttothepmvisiouofoftheB Both.
nixnseLaw(Chapter9 Sq.F[. Floor Area Valuation
u F S (commencing with Section 711!10)of Division J of du BusinessaM Prtifessiom GaM)or
$250000
_ that he u exempt therefrom and the basis for the alleged exemption.Any violation of
Sudors 7071.5 by any applicant for a permit subjects the applicant to a civil Penalty of APN Number Occupancy Type
not mote Nen Ore hundred dollars(3500k
P Y YP
❑1,u owner of the property.or my employees with wage as Neu sola compensation,
will do the work,and am swoon,is not intended or onerad for side(Sec.7014,Business
asW Profession Code,The Communities License law don rot apply an an Owner of Required Inspections
property who builds erimprovu Nercon.atd who doessuch work hitnulfor dough his
mere employcu.provided Nat such improvements ere nal intended maneud for side.If.
however.the building or improvement is sold within We year of completion,the owner.
Wilder will hoe du burden of proving Nat W did not build or improve for intones,of
sale).
❑1,as Owner of the property,am exclusively contracting with licensed conmmums to
construct the project(See 7014.Business and Pro(esaws Cade:)The Conmamots U.
eeue law dose nos apply an an owner of property who builds w hmp.0umon.and
who commasm far such prej..with a rnnuacuKs)licensed pursuant in the Contranlo(s
License Law.
❑ 1 on temps under Set ,B d:P C for this,season
Owner Dau
WORKER'S COMPENSATION DECLARATION
I hemby aRm under pe iy o(perjmy one e(she roto ng dadarmions:
I have and will mdnuinaCutifiau ofConecmaself-iuuu fm Warkees Comp,n-
cation,as provided far by Section 3700 of the labor Code,fm the Perform..of Ne ,.
woes for which Nu permit u issued.
❑1 have and will maintain Workers Compensation Insunna,as required by Section -
1700 of she Labor Code,for the performance of the work far which this permit is Issued.
My Workers Compewsion lmsureae cmrie and Policy number art: I
Croner. Policy No.: _ n t 1`
CERTIFICATE OF EXEMPTION FROM WORKERS' - IJ 2_`xaJ�
COMPENSATION INSURANCE
(Thu section reed natbecanpleud if the permit is foram hundred dollars(3100)
or lcsS)
I eerily Na in the parformancc of the work for which this permit Is issued.1 shall trot
employ any Person In my manderso as ta Woman subject be NC Workel5 GompenaaYon
Laws ofcallfomia.Dam
Applicant
NOTICE TO APPLICANT:IL ofr making this Certificam of Exemption,you should
became subject an the wmkefs compensation provisions or due Labe Code,you mut
.,O forthwith comply with such provisions or this permit shall he deemed otwil d.
zvy CONSTRUCTION LENDING AGENCY
'rt 1 hereby anirm dud the.isaeomow6mo lending agcn forth peif...of
D: the work for which thus p�rlpit i Ocd(Sec 3M7,Civ.C.)
aQ fender's Name t�1-ONF-
r0 z Lemmen Adduce
V Q - I certify Na 1 haw rad this application and suis that the above information is
Uy Fcorrect.I agree to comply with all city and county ordinances and sum laws minting to
0 U building construction,and hereby authorize representatives Of this city to enter upon the
Lo
abovomcmiuncd property ford expenses
xpo ses rituPowhich s.
(We)ague to saw,indemnify and keep harmless the City or Cupertino against
UZ incaides,JWgmcnu,griming or this,emay in anyway attrec agaitut said City
Uz ActinuquNT of the Rantingarthis permit. a%
^ A PLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
5 0.CE EGg ULATIOfJS. „
L,as 1--icarti'fa yractor I Dame l Re-roofs
Stgvturt of ApplicanVContracanr Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant same or handl,haardau material
as defined by Ne Cupertino Municipal Code,Chapter 9.12,and tM Health add Safely ...
i
,Section 255J2(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yu )<aWBI din a ftnant al faire Wildin area ant ts< If a roof is installed without first obtainin an ins ection,I agree to remove
PP e P ea Air Qu ar device whim g Pharardnu air contaminanss u dchned by the Day Arca Air Quality Managcmcm all new materials for inspection.
n? � /
❑Yes \ `(No
I have read the haeandous\materials tequirtmcmu under Chapter6.95 of dm Cabin,
isHulthk Safcty Cade,Sectiar2 5,25533. n334.Iunderstandthati(the Wilding
s not eurremly how a tenant that k is my reatimunbility xi ddi lY de aapant of the
re awnm rot m priorwjsstna ,c 0nma170upay. Signature of Applicant Date
12416 D
Owner Or authorised agent Dou I All roof coverings to be Class "B"or better