04040107 CITY or cvrEarNNo CONTRAC
BuTOR INFORMATIONBUILDING DIVISION PERMIT
BUILDING ADDRESS: L ED WESSLER PERMIT N0.04040107
10380 CRESTON DR
OWNER'S NAME: PERMIT ISSUEDATE
L ED WESSLER 04/16/2004
SANITARY NO. CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTIR ACTOR'Snsedma ,pamemDECLARATION Job Description
rd I hereby affirm Ihat I em licensed under provisions of Chapter 9(commencing P
with
Scnion 9IXM17 of Division J of the Buairtra eM Prufcuinns Cndc.and my license is
ra y infull fareeAnd efmn. ADD 103
SQQy/./Fl,ST�. /BATHRM REMODEL
JZ License Class
Dale
ARCHITECTSDECLARATION � 2
I undcrsmnd my plans Mall he useda public
�
�-
mcmtls V
;at; Licensed Pmfcssional
y0g OWNER-BUILDER DECLARATION
N
tn O I hereby mason,(Sec that 1 1. exempt from Ne Conln,Cat :Any c Lew co the
O o which aPermit
i ?onstr Business and Pmfcaio li Code:Any city mcoumy
K$� whichastrequires a panties m aims the
alter,impmw,demolish,or repair any statement
3
yds^ Prionnitscensed pursuant
arcquircnhovisios applicant anchpermil loflcasigned LAW(Chapter
cm
£x< (co mencernwitpursuanttotheOfDivinun(theheBmirmsLlecrxssions Code)
Sq.FLFloor Area Valuation
y F$ Or,he I.exempt
therefrom
And th Diviniofar O the,.d essand Professions Cade)of
Q�.• Nm he is exempt thert(rom and tirt buil for the alleged exemption.Any vinlatlan of
Section 9031.5 by any applicant for a panni,subjects the applicant to a civil penalty of � (q.00 OCCUanC e
not more man fiw hundred deRara($500). P YgYP
❑I,a owner of the property,or my employers with wages As their sole compensation,
will do the work,and the straclux is not intended or offered for sale(Sec.71344,Business
and Professions Code:The Contractor;Lice.Law docs not apply to in owner or Required Inspections
propeny who builds orimprows thereon,and who does sw1twork himself or through his
ownemployces.provided that such improwments are not intended or offered for ale.IL
however,the building or improvement Is sold within one war of completion,the owner-
builder will have the burden of proving that he did not build or Improve for purpose of
sal'.).
❑I,as Owner of the pmpcny,am exclusively contracting with littnxd contractors to
construct LA the es nor(Sec.7W,Business and Professions ds or The Conusmon, rad
cense Law docs nm apply a to owner of property who bullae or Improver thereon,and
who.Lacts for such projects with a comnaar(Q licensed pursuant to the Canuadorl
yiceese Law.
❑I am exempt under Sec. Da a P C fm this maven �/
cr pale
KER'S COMPENSATION DEC R N uQ /
1 hereby anon under penalty of perjury one of the foil wing declamt arts:
I have and will maintain aCenlacom of COmarI to self-insum fur Werke;sCompen-
sation,u provided for by Section 3?00 of the labor Code,for me Performance of the
work for which this Permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,a required by Secton
37Wof the labor Carl,for the performance of the work for which this permit is issued. '
My Worker's Compensation Insurance canner and Policy number art:
Currier. Policy No.:
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
(This mann need not he complewd if the Noun B foronc hundred dollars(51010
or Mss.)
1 cenify mal in the per ante of the work for which this Permit Is Issued.I shall not
employ any manner was m b�cyn�p'{t I th r Compensation
Lawa,fic.eli(orni. �f(Mi L1lGd �l,
NOTIC P ANT:If, far making this Cenifcate of Exemption,you rimula
beer a joe,to,he Wmkei s Compewrlon provisions of the Iabnr Cude,you must
eJ,z foMwilh comply with such provisions or this Permit hat]he deemed¢caked.
zO CONSTRUCTION LENDING AGENCY
.�
I—t I herebyaffirmmarmite haed(Sec.3071ndinpgency for the Performance of
DJJ the work fur which this permit Is issued(Sec.3(N?.Civ.C.)
Wa Lenders Namc
z Lcntler's Address
V C) 1 cenify mu I haw rad this application and sate that me shove information is '
IL H coned 1 gree to comply with all city and county ordinances and state laws relating to
OV building convection,and hereby maintain represcroadws of this city to enter upon the
C alwrc-mentioned pmperly for inspection purposes.
(We)agree to saw,indemnify and keep harmless[be City of Cupenine against
f+h liabilities,judgments,cast,and expenses which may in any way accrue against said City
in consequence of gaming of this permit.
t�
APPLILF4T UNDERSTANDS AND WILL COMPLYW TJ H ALLj.'ON-POINT Issued by: Date
SOU G LATIONS.stgnture � /�,y�Zl11rL Re-roofs
ppltcaHAZARDOUS MATERIALS DISCLOSURE Dex Type of Roof
Will the applicant at futuw building occupant store or handle haaAaus notarial
az deRned by On Cupertino Municipal Code.Chapter 9.13,and the Health sad Safely
,dMCode,Srmon 33532a)7
❑Yea �(Na All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
70�wmcrmamhahnda,rao
havardour air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
ric,?
❑Yes lyNu
I haw mad the haaardou''s m``aisrials requirements under ChaplarA95 of the Califon
ealth 1k Safely Code,Secfiun 25505,35533 and25531,I undemmnd that if the building
not currently how a tnnanl.that it is my mapamehilily to an il'y On occupant of the
• i cots which mum be mel Prior or issuance of a Camm of Occupancy.
Signature of Applicant Date
D x All roof coverings to be Class"B" or better