05100055 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS: GOFF DEVELOPMENT & DESIGN =""005100055
21887 WILSON CT
OWNER'
791 E BROKAW RD 11 /99/9005
IRK: SANITARY NO. CONTROL NO.
(408) 441-8076
BUILDING PERMIT INFO
ARCHITECTIENCINFER: BLDG ELECT PLUMB MECH
Z' LICENSED CONTRACTOR'S DECLARATION Job Description
gI Acodby aftim,But I Am licensed under provisions,otChapier 9 Rommancing
..iLh Section 700OWDIviim,3 offt Busimsmand Prof..ionsCmic.and.yfic.m.is
L rilf ndaff ADD 12051 DINING/FAMILY/MASTER
jjg p: .q: Lim.0—
Dem CO.. REMODEL KITCHEN/BATHROOMS
'T'DECLARATION ECLARA71ON
urdemard my plane shall Ito cand As public records
Licensed Pratessi...I
h OWNER-BUILDER DECLARATION
��12 1 Wmby afnno That I am exempt from We Conumeter's License Law for me
CaC fallowing resume.(Section 703 1.5,Business and professions Code:My City Of county
ISE! which mq.j=4 permit us...smuca�Aw.imprem.dernofth.Or Fair any summuou
prior 0 Its ism—o,al-"Ohm;%WMm,In,Rich permit to 11,a Mason statement Val X18®540
that Isc is licensed pursuard to the pmisi...f the Confroame.License Law(Chspw 9 Sq.Ft.Floor Area
(commencing wire Satim 7000)of Divielan 3 of dm Businose wd Profwions Cade)or
due he is sucempt therclosen And tire bash for law alleged examprion.Any violaikan of
Secdon 7031.5 by any applicaurt for A Permit subjects the BppHCVE to a civil penalty Of ber Occupancy T�pe
not more than an hundred dollars(3500). 3 M4 M8 . 00
0 1,As ww ofthe property,ca my employces,with August a their miccompensadon.
Mlidoftwrk.ndihcsmctumi,mli.u.dcdoloffmdf.,Sale(SW.704"4.BWnues
and Profession Code;Tint Contractor's License Low does WE Apply 0 An OvOlm Of Required Inspections
propmywho build,orimproveadvown.and whodoestuchwashidnieftarthroush his
oust employees.provided thatsuch impmarla are notifflexhad m0fleffed fM5&If.
however,the building or Improvement is sold Ambitious)cs,of completion,We mumm-
budder sift brom the burden of immmi,that he did an,build or improve for purpose of
ale.).
C]1,As owner of the Property.Ann asebusurvely contracting who licensed contractors;to
coommal Me Mica(Sac.70th,Basunces and Potficausears Cod.)The Commusau'A Ll-
.Law does ace apply to an,.Of pmperty-wito Wilds.r leassevex ft..and.
who cooneu for such pmj.c%with aeontracmrtA Hecrund personal I ft C.MMAILOO'S
License Law.
0 1 am exempt order Sao 'a&P C for this reason
own. Data
WORKER'S COMPENSATION—DECLARATION
I ineeby Sam under penalty of perjury am of the following declarations:
An And will maims n.Casufleme of omen,An self-lamme r.rWarkeesC.pn.
A.as provided for by Section 37W of ft Labor Costs.for Out performance Of ft
work far which this permit is turned.
0 1 haw and will maimm,Worker's Comparmadon Immune,As required by Section
31700 of the Labor Code.for the performance of the work for which this innei,Is Issued.
MY Worker-
Co AwiVtAxuW4&c&ffi d Policy O.mw am:
My Workees No.:
CERTIFICATE OF EXEMPTION FROM WORKERS*
COMPENSATION INSURANCE
(rds section need nottsucomplemd Box,Fund,is forcutchundred deffm($100)
or WL)
I cerdCy that in the perform..Of the soh for which this permit is issued.I shaft not
employ any person I.any matmer An As to become subject to ft Workers.comperstation
Law,of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Cardficam of Exemption,you Mould
become subject An Ma Workers Compensation previsions of ft Labor Cede,you must
Z
forthwith comply with such provisions"this permit shall th,decreed rawkcd.
ZR CONSTRUCTION LENDING AGENCY
CA I luemby aflum But,them Is a construction Icrulfing agency for the performance of
fY> Me Anork fur which this permit Is issued(Sec.3097.Civ.C.)
ELender's Name
M Lenders Address,
U Q I ocnilly that I have read!this applicadme And sum than the Men Information in
U, toren.rm"'"gra'0 comply Am"all city And county waamrses And sum lam mlatins In
0 Wilding commuction.and WrohymOvenee mpoascoudws of this City to now upon ft
abow-mentioned property for Inspection purposes.
0. (We)agree to an.indemnify And kap Wooless the City of Cupertino AlLimst
rA flabiliUms,judipmmu.coam,and expencun,which may in my my accrue against said CRY
J,Z in consequence of the graining of Bus permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date Z 41
SOURCrGULATIONS.
I 0
ki d — Re-roofs
Signature ofAppliwVC r % Data
a �%S MMK4 DISCLOSURE Type of Roof
0
ILAZIFD
,fun
WdIubA.ppIftZ r future building occupaUstom Orhandle huardous malcrill
As dcflncd by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
0y. '%tL
Will ft applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hAOcAdWs air cutuammants As dicriond by ft Say Am Air Quality MAMISCOMM all new materials for inspection.
Viet?
0 Yes We
I have reall the hatcardunnammals muluftenums under Ompmeil.95.fdon Califor-
ala,Health&SAAclyCodo.SmmonA2S5a5.2SS33 And 25334.1udenund ottaffinc Wilding
does not currently ban a Aman,dust it is My responsibility At no'fy the OcetmML Of ft
mqut.ru hkb oves,W isance
m .r.certsfiettamfonqupil <- Signature of Applicant Date
eulv_� ;W 11f"
5—..r or wduirife4plif'On, I datc All roof coverings to be Class"B"or better