B-2016-1359 (Permit)CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-1359
10590 N TANTAU AVE CUPERTINO, CA 95014-0708 (316 06 063)
(RUDOLPI-I & SLETTEN
INC)
REDWOOD CITY, CA
94063
OWNER'S NAME: CAMPUS HOLDINGS INC
DATE ISSUED: 02/18/2016
OWNER'S PHONE: 408-996-1010
PHONE NO: 415-297-0528
Class a Lic. #198061
or( RUDOLPH & SLETTEN INC) Date 02/181201E
hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
ith Section 7000) of Division 3 of the Business & Professions Code and that my
tense is in full force and effect.
hereby affirm under penalty of perjury one of the following two declarations:
1. I have and will maintain a certificate of consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
"��/z. I have and will maintain Worker's Compensation Insurance, as provided for
by Section 3700 of the Labor Code, for the performance of the work for wbi
K
this permit is issued.
APPLICANT CERTIFICATION
certify that I have read this application and state that the above
nformation is correct. I agree to comply with all city and county
trdinances and state laws relating to building construction, and hereby
authorize representatives of this city to enter upon the above mentioned
aroperly for inspection purposes. (We) agree to save indemnify and keep
iarmless the City of Cupertino against liabilities, judgments, costs, and
:xpenses which may accrue against said City in consequence of the
panting of this permit. Additionally, the applicant understands and will
:omply with all non -point source regulations per the Cupertino Municipal
Dode, Sectign 9.18.
Date 0211812016
hereby affirm that I am exempt from the Contractor's License Law for one of the
Blowing two reasons:
1. 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 (Sce.7044, Business & Professions Code)
r. 1, as owner of the property, not exclusively contracting with licensed
contractors to construct the project (Sec.7044, Business & Professions Code),
hereby affirm under penalty of perjury one of the following three declarations:
1. I have and will maintain a Certificate of Consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
z. I have and will maintain Worker's Compensation Insurance, as provided for
by Section 3700 of the Labor Code, for the performance of the work for which
this permit is issued.
s. 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
Worker's Compensation laws of California. If, after making this certificate of
exemption, I become subject to the Worker's Compensation provisions of the
Labor Code, I most forthwith comply with such provisions or this permit shall
be deemed revoked.
APPLICANT CERTIFICATION
I certify that 1 have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws
relating to building construction, and hereby authorize representatives of this city
to enter upon the above mentioned property for inspection purposes. (We) agree
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant
understands and will comply with all non -point source regulations per the
Cupertino Municipal Code, Section 9.18.
PERMIT INFO:
BLDG —ELECT —PLUMB
MECH _ RESIDENTIAL X COMMERCIAL
DESCRIPTION:
Phase U: Tantau 3 Office Tenant Improvement (3000 sq ft).
Ft Floor Area: Valuation: $50000.00
APN Number: Occupancy Type:
316 06 063 1 B (Tenant Improvements)
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
3/2016 �9N
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Lure ofAppl
02/18/2016
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California IIealth & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Cade, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 d
the Health & Safety C de, Sections 255f 5, 533, and 25534.
Owner or authorized agen .
Date: 0211812016
I hereby affirm that there is a construction lending agency for the performance
of work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Date 0211812016
Licensed