04120147CITY OF CUPERTINO
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PERMIT
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.s�CQRiNFQBUILDINGDIVISION
BUILDING ADDRESS:
TRESSLER EXCAVATING, C E
PERMIT NO. 04120147
OWNER'S NAME:
DR
PRRMITIB9URDATH
nA Zoo /2
g:
SANTfARY OATO
OL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0
LICENSED CONTRACTOR'S DECLARATION
lb Description
o
1 hereby ofOrce that 1 em licensed under provisions of Chapter 9 (commencing
with Section 700B.1' Division Sof Met Bum. And Po esdotn Coda. and my license B
in full function! effect. =�-�-5 Q 34,
LicenseClo. A LIc.B `�
DEMO
Data Contractor
FEES CORRECTED(O2/22/O5)
ARCHITECTS DECLARATION
I understand my plans 'hall Ise used u public records
CHG VALUE FROM $7000 TO $8750 -PER OWNER (02/22/
Licensed Pmfeuian.I
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contactors License Law for the
fallowing moon. (Bordon 7031.3, Business and Professions Cale: Any city Or county
which mqulms a Permit to Cmstmaa het, borrow, demohinh, or repair my mmwm
prior in its Issuance. atm mquimi Me Applicant for such Permit to file. signed statement
Sq. Ft. Floor Area
Valuation
that be is licensed pursuant "the provisions of rite Cmlrscturs License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and Me basis for use alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.3 by any applicant for a permit subjects Me Applicant to . civil penalty of
not more thin flw hundred dollars (113001.
omploycea withwsgnsa compeusines,
wi Lirownerotthe parmucl
'%51402'%,00 Required Inspections
n Is formic m. 7O N,
will dothssion and Nemuctumbnul,Limmit intanded nawit
water of
and Profession Cade: The Cnnuumh License law dons not Apply lf an owner
tapply
Mr
property wh wank himself is
property who buildsofimprove McIcon,And who dmnot
mounted ed formal
awn employees, provided Ilan Imprownmms am notonsofm Deere. formal.
however, the building or Improvement h hath within one year of completion, the ownel.
vent
builder will have the burden of proving that he did not build or Improve for rugose of
rats.).
0 1. as an. of the property, am eschusiwly contracting with Ilcenseh mntnm9la to
consumer the project (Sec. 7044, Business and Professions Code:) The Contractors LL
cense Law does nal apply in an owner of property who builds or improves Merton, and
who contracts for such projects with s contractor(O licensed pursuant to the Contractors
License law.
❑ lamexemptunder See. ,BAPCfmthismum
.or Data
WORKER'S COMPENSATION DECLARATION
I hereby aRms under penally of perjury ane of Me following declarations:
❑ Iham and will maintain CenifLLYle of Conham to self-hsum f"Warmer Coni
salon, On provided for by Section 3700 of Me labor Code. for Me performance of the
work for which this permit Is issued,
0 1 haw and will minimal. Worker. Campewllan Inssmm, no required by Section
3700 of Me Labor Code. fm the pemomanee of Me work fa which Nis permit i. Wued.
My Workeeg Compenalion Insurance
�aartife-rfand Policy Wirer am:
�b
Caller. $'CAYg Wim^"'--W�Ito, Nor: � 145>0 1,9
CERTIFICATE OF EX EM FTION FROM WORKERS6O/L.S
COMPENSATION INSURANCE
T
(This section need not ccorpleted IOhe perchlsforanchundmddollen(510)
or Ins.)
I cenify Met In the pe,fomenee of the .,it for which this permit D Issued, I Nall am
employ Any Person in my manner an as in hreame subject to Me Workcri Compensation
Laws of Cdlforoi r. Date
Applicant
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should
became subject M the Worker's Comperustion provisions of the labor Code, you mum
foMwith comply with such provision in this Permit hall M darned revoked.
CONSTRUCTION LENDING AGENCY
1 hereby o1Ttrm that them is com uctlon lending agency for Performance lir
the work for which this permit is issued (Sm. 3097, Cih, C.)
Lenders Num
Landers Address
1 certify that I have rod this pplication and mte that Me above Inromallm Is
comm. l pone to comply with all city and county ordhram'es and sun laws rzlabna to
Wilding construction, and hereby authorim repruenutiw. of one city to enter upon Me
AbmomemionW property for inspection puresea
(We) agree to raw, indemnify and keep hamlet Me City of Cupertino against
Ihbllilies, Judgments, costs and expenses which may In anyway acme against said Cally
In consequence of the grammg of this Permit.'
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINT
Issued by: Date
SOURCREGULATIONS, I
y
Re -roofs
Roof
Signnurtl pplinn anlnclrr Dam
HAZARDOUS MATERIALS DISCLOSURE
Type of
WIII rite applicant lir forum Wilding occupant store "handle huArdous material
u defined by tit CupenMo Municipal Code. Chapter 9.13. and the Health and Safely
Code, section 23133(,)7
All roofs shall be inspected prior to any roofing material being installed.
D Yus PLN.
If a roof is installed without first obtaining an inspection, I agree to remove
WIII the applicant or future building Occupant use equipment or dcvlms which
emir havArdoua air comedbors u dclned by the Bay Area Air Quality Management
all new materials for inspection.
District?
1-1 Yen �No
I have road the harArdms materials lequiromcn s under Chapter 6.95 of the Cabral.
rata Harty@ SafeuyCode, Soctiau 23313.25533 too 25334.1 urAmtsM Men done building
doer nor currently haw a tenant that It u my responsibility M notify the oceupmt of Me
require nIs which must Wmet 'or teem aCom0esaor mprcy.
Signature of Applicant Date
CA -
-AH
All roof coverings to be Class "BI' or better
Own huarixadl Dale