06090148 7 77
CITY OF CUPERTINO � RT � fi
BUILDING DIv1SION PERMIT
BUILDING ADDRESS: RUDOLPH & SLETTEN INC PERMIT No. 0 6 0 9 014 8
19111 PRUNERIDGE AVEPERMIT ISSUE DATE
^`LNER'S NAME:
HEWLETT-PACKARD 1600 SEAP
SANITARY NO. CONTROL NO.
PHONE:
(650). 16-3643
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
00 LICENSED CONTRACTOR'S DECLARATION - Job Description
V
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
z m with Section 70(10)of Division 3 of the Business and Professions Code,and my license is
<0- in full force and TI-INSTALL NEW 900 .TON CHILLER & PUMPS IN
�? License 1 L� " ��O EXISTING CHILLER ROOM
t•-tp Datc Contractor
ARCHITECT'S DECLARATION
C< I understand my plans shall he used as public records
L<
yU
u.in Licensed Professional
iOWNER-BUILDER DECLARATION
> I hereby affirm that I am exempt from the Contractors License Law for the
cc following reason.(Section 7031.5,Business and Professions Code:Any city or county
1c'Pi which requires a permit to construct.alter•improve,demolish,or repair any structure
I -H prior to its issuance,also requires the applicant for such permit to file a signed statement Vall�q(Bio 0 O 0
S Ft.Floor Area
?< that he is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 9 fl
t= (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 Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number
not more than five hundred dollars(5500). 3 1 6 0,7 0 4 2 . 0 0
❑I,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
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(See.7044.Business and Professions Code:)The Contractor's Li-
cerise Law does not apply to an owner,of property who builds or improves thereon,and
who contracts for such projects with a contractors)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sec. B&P C for this reason
--vner Date
WORKER'S COMPENSATION DECLARATION
hereby affirm under penalty of perjury one of the following declarations:
I have 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.
elhaveand will maintain Worker's Compensation Insurance,as required by Section
3700 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:
Cartier./ FJIIC At1� &M"haocY Na.: .34415-307"_
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($I00)
or less.)
I certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner so as to become subject to the Workers'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 Code,you must
,J Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z 0 CONSTRUCTION LENDING AGENCY
E.,t-• I hereby affirm that there is a construction lending agency for the Performance of
the work for which this permit is issued(Sec.3097,Civ.C.)
W QLender's Name
�
Z
Lender's Address
U 0 1 certify that I have read this application and state that the above information is
IL H correct.I agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
nW.
(We)agree to save,indemnity and keep harmless the City of Cupertino against
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liabilities•judgments,costs and expenses which may in any way accrue against said City r
V Z in consequence of the granting of this permit. Date
APPLICANT U E TANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOUR( ULATIO
;'n�2
011'06 Re-roofs
Signatfire of Appli tractor Dare T of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
Will the applicant or future building occupant store or handle hazardous material
as defrncd by the Cupertino Munici�o Code.Chapter 9.12,and the Health and Safety
Cock,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes 4640
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?
❑Yes Nu
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the building
does not currently have a tenant.that it' responsibility to notify the occupant of the
requiremen prior to issuanc of a Certificate of Occupancy. Signature of Applicant Date
9-d-0(' All roof coverings to be Class B or better
O ner Ar-authorize Date