03080113 (3) FI-,B' Q
TY OF CUPER'I'INO
BUILDING DIVISION PERMIT CONTRACT ORzANFORMATION U
DwGADDRESS: RUDOLPH & SLETTEN INC "°03080113
R'S NAME: 989 E HILLSDALE BLV PERMIT ISSUE DATE
NE: SANITARY NO. CONTROL NO.
(415) 572-1919
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+Oa LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions or Chaptcr 9(m mcncing Job Description
M! with Section 7gMp or Division 3 ofine s,ncns and Professions Code,and my l rials
in full anti c. �(j
iq= Limn 'u k� �Lat.t 806, DEMO
yr Data
fWi114I
ARCHITECTS RATION
lu 1 under__
° stand my plans shall M used as public records
'dr
��', Licensed Pmfssional
h� OWNER-BUILDER DECLARATION
�<f 1 hereby reaso affrm that 1 1. exempt son me Contractor's License Law for the
p O Which following tiles a.(Scctian 71131.5,Business and improve.
do ions Code:Any city s county
5$ which its issuance,
n permit to char the
alar.improve,h Permit
ermt t or repair any swarm
Zi prionnitscensedp rsualso requires thovisiapponm forns of the sucConpermiuoiense Law(Cha mem
22mmO (commthat he escingwJpurction7( )ofDivision3oftheBulactsandPrulaw(Chopmry Sq. I. Floor Area Valuation
2F (cat he
(commencing Section7(M) baiiioI,of the Businescond Professions Com)or
Net he is exempt therefrom and Ile Ease far the alleged eempsion.Any violation of 31607,046 . 00
Section 7031.5 by any applicant for a permit subjects she applicant to a civil penalty or APN Nb bee Occupancy Type
not mom Nan five hundred dollars($500).
El I,as owner of the pmpeny,car my employees with wages is their sets compensation,
will do the work,and be swnure is net intended or offered for sale S.C.7044,Business 704 LIEMRequired Inspections
and Professions Code:The Contractors Licente,Law docs not apply to an owner of q p
property who builds or improves thereon,and whodeas such work hiceselror through his
own employees,provided that such improvemenu are not intended or offered forsale.If,
however,me building or improvement Is sold within one year of completion,the owner-
builder will have the burden of proving that he did net build or improve for purpose of
sale.).
1,as owner of the pmperty,am exclusively contracting with licensed conwaorx to
construct be project(Sec.7044,Business and Professions Code:)The Contraction's Li.
cane law docs not apply to an owner of progeny who builds or improves sheeon,and
who contracts for such projecu wish o centranor(s)licensed pursuant o the Contractor's
Liccnu Law.
❑1 am exempt under Sec. B k P C for this...a
r Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
1 have and will mai nein a Certificate or Consent to ulbimu i for Worker's Compere
sation,as provided for by Section 3701 of me labor Code,for the pctf.moned of the
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance.as required by Section
37W of yyc LeEor code,for the performance of the work rLwtych tBq IsaiiS. .
My War�kr's gptpe s inpingwa1XN((gjpg'�d� l� 1ftN00 2%
CERTIFICATE OF E%EMvFROM WORKERS'
COMPENSATIOAAAAAA111111NNNNNNSURANCE
(Thin section need not M completed if ren permit is foram hundred dollars(Siff)
or less.)
1 certify But in the imfotmmee of me work for which this permit is issued,I shall nut
employ any person in any manner m a in Become subject to the Work.rs''Compcusatlon
Laws pf California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Cendleeu of Exemption,you should
became subject to the Worker's Compensation previsions of the Labor Code,you must
�z rordiwi on comply with such provisions or this Permit shall Ito doemsedl mvitsid.
zl O CONSTRUCTION LENDING AGENCY
F" I hereby affirm Nat mem is a Conswction lending agency,for the performance of
a > she work for which this permit is issued(Sec.3W7,Civ.C.)
W 0 Lcndcr's Nom.
az Lender's Address
U 0 1 certify that 1 have mad this application and sou that the above information is
LL F Correct.I agree to comply wit all city and county ordinances and store laws relating to
0[, building run ion.and Beeby euNorie eprcenutiapuf this City to enter upon the
tS7 ahovcmeni d property for inspection purposes.
(W a rte m mvc,indemnify and keep hmmless the City of Cupertino against
C1. liabilities ud ,costs and eapcnses which may in my way seem,against mid City
V z in Co. ren t of,mmingu is permit (/Y/
'-' APPL A N ERSTAN A WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU ER L 10
21 of Re-roofs
rare pli nUConrumr Dau
HAZARDOU MATERIALS DISCLOSURE Type of Roof
Will to plicamurfwnu uilding occupant me or handle ha7mous material
I III d by the Cupertino Men cipal Code.Chapter 9.12,and the Health and Safety .
.Section 2553 2(a)?
�/JJJ...� All roofs shall be inspected prior to any roofing material being installed.
C]Yea
dna
Will the applicant or future building occupant Liu cyuipmenl ar devices which If a roof is installed without first obtaining an inspection, I agree to remove
\47t�qairc
hazardous air conuminanu as dermal by the Bay Area Air Quality Management all new materials for inspection.
❑Y1 vc ]nus materials reyuiromcnu unJcr Chapurfi95 ifthcCalifnacol &S Section )5,25533 and 75534.1 undernmd that if Be uilding
not cart a serum that tu my malmihilay u notify the mcup of de nu Jr.ich stoic . nor ussimee.fac.mrcm,r cu g 1 Signature of Applicant Date
A.
Dau All roof coverings to be Class "B" or better
e ser au rias gent