06090149 CITY OF CUPERTINO �'�t' h,�
BUILDING DIVISION PERMIT 4OA
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BUILDING ADDRESS: RUDOLPH & SLETTEN INC PERMIT No. 0 6 0 9 014 9
19111 PRUNERIDGE AVE ft 44
PERMIT ISSUE DATE
^WNER'S NAME:
HEWLETT-PACKARD 1600 SEA
PHONE: SANITARY NO. CONTROL NO.
(650) 216-3643
ABUILDING PERMIT INFO
RCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION Job Description
u I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Uw with Section 7000)of Division 3 of the Business and Professions Code,and my license is
�y in full force andel et p'
lass^ REMOVE EXISTING CHILLERS & ASSOCIATED PUMPS
�? License CLo•x �'MAbUft IN BLDG 44
t„-,w Datc — Contractorr
ARCHITECT'S DECLARATION
a< I understand my plans shall be used as public records
tyU
'
U.H Licensed Pmfcssional
'H OWNER-BUILDER DECLARATION
1 hereby atTirm that 1 am exempt from the Contractor's License Law for the
00 following 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
?Zy prior to its issuance,also requires the applicant for such permit to file a signed statement
< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Val>rz; 0 0 0
Fz (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars($500). 31607042 . 00
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of q
property who builds or improves thereon,and who does such work himself or 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,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
ccnse Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sec. B&P C for this reason
1wner Date
WORKER'S COMPENSATION DECLARATION
}hereby affirm under penalty of perjury one of the following declarations:
al-ha.
es-hha ve and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
Rt'ttia-and will maintain Worker's Compensation Insurance,as required by Section
00 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number arc:
Carrier. �t (eA�� (all� o.:-_ 06 _
CERTIFICATE OF EXEMPTION FROM WO KERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I cenifv that in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner so as to become subject to the Workers'Compcnsalion
Laws of Califomia.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 Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
p!> the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lenders Name
az Lender's Address
U O 1 certify that 1 have read this application and state that the above information is
L>~ correct.I agree to comply with all city and county ordinances and state laws relating to
O U building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. /17
W
(We)agree to save,indemnify and keep harmless the City of Cupertino against
fly t) liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit. / y
►+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date i�!
SOURCE REGUL
(Q►l�06 Re-roofs
Signature of Applican ontractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ,o"
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
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
C]Yes
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
[docs not currently have a my responsibility to notify the occupant of theuircmcn u et prior to iss ce of a Certificate of Occupancy. Date
Signature of Applicantncr or authors. gcnl Date All roof coverings to be Class"B"or better