06050217 CITY OF CUPERTINO ��r^y. 's,gb"-*'` '' " �T��'a �,{ moi
BUILDING DIVISION PERMIT y �l\�Ll\taOT RWt1,A'ONM ATION iz
BUILDING ADDRESS: GOFF DEVELOPMENT & DESIGN `IITNO'06050217
21887 WILSON
OWNER'
SANITARY NO. CONTROL NO.
(408) 441-8076
A0.CHiTECnEiVGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
ipp LICENSED CONTRACTORS DECLARATION
w 1 Mxby offs,¢Net 1 em licensed antic,provivans of chaprer 9(tmenom cin, Job Description
�U withSeedma7004))af Division 3ofJme Budnasatb Prafasiou Coum.andmy licpnxei4
in full mxeand ely«t REVISION-2ND FLR JOISTS/MOVING WALL BETWEEN
Lieenx Its Ide.p
Dam TSDECL KITCHEN & DINING RM-ORIG #06050217
yy ARCHITECTS DECLAR n
i K< 1 on rm d my plans shall he used as public records
ayu
y Licensed Profcasional
h 3 OWNER-BUILDER DECLARATION
I I hereby alliin Nat 1 am acmpl from the Commences License law far the
:p O fallowing soon.(Section 7031.5,Business and Pmfeuiou Code:Any city or county
$E which requites a permit to em t.vier,improve,demu lads.ar mpair any structure
'.zi prior to its ismance.at.squires Neapplicasl for such permit,.file.signed ulemem
<
that hcupursuant licensedpursuanotheprovisionsoflheCotrctorsLicese, aw(ChaPrm9 Sq.F[. Floor Area Valuation 0
�FG (commencing with Section 7")ofDivision 3 of use BuSness and Professions Coom)or
$
that M It exmpt tMsfrom and the basis for the alleged maropdon.Any violation of
Section?031.5 by any applicant for a Permit subjects lie applicant an a civil Penalty of pp N Number Occupancy Type
not more Nan five hundred dollars($SM. 3 2 64
9018 . 0 0
I,uo mrof Uepropmy,mmyemploycrawiNwaguu Noirxlecompewdon,
willde Ne work.and the suunureunotinuMed aro@red forsamisec.7046.1business Required Inspections
and Professions Cade:The Ccomecxer's License Law does not apply to an avow of q p ,
property who builds wimproves Netcom,am whodoessuchwork hi mofforthrough his
Own employees,proWded Nal such improvements are notinended ororteted fatale.If. -
however.Ne building or improvemen.is said within one year of completion.the owner-
Wilder
wBl have Ne burden of proving Nal M did not build or improve for purpose of
We.).
❑1,as ow.of Ne property am uclusivcly caroming with Ocmued anuanon In
coaumt Ne project(Sec.7014.Business sM Profession,Cade:)The Communes Li. ,
cease law docs not apply to an owner of property who builds or improves Nexor,and
who ommucu for such Projects with a coom mur(s)licensed pursanl to on,Conuaetaes
License law.
❑1 am exempt under See .B k P C for this masan
mer Dam
WORKERS COMPENSATION DECLARATION
I hereby affmno under penalty of perjury ore of the following declarations:
❑Ihave pod will Sects..
Sox of CmuentmCodleuux a Watkch Compere
nation,r Provided(pe an S ision 3?00 0(Ne Inbar Cade,far Ne performemc of Ne
work for which this permit u issued.
❑1 have and will munuln Worker's Compensation Inxnmce,u sequined by Section
37W of the Inbar Code,for Ne performance of Ne work for which Nu Permit u asted. '
My Wmiafs Compensation Insurance artier and Policy,umber are: -
Caromr. Policy No.:
CERTIFICATE OF EXEM MON MOM WORKERS'
COMPENSATION INSURANCE
(This section rcN notbe cmnpldmd if Ne permit Is(mane hunNrddoRara(5100)
or leu)
I cenih that in the performance of Ne work for which this permit Is;tasued.I shall am
employ any person in any mannerx as to become subject to the Workers ComPeuauan
Laws of California.Date
APPliam
NOTICE TO APPLICANT:IL after making this Cenifiam of Exemption,you should
become subject to Ne Workch Compewuon provisions of the lahm Cade.you muss
.J z forthwith comply with such Ironstones or this Permit shall x domed matted.
?O CONSTRUCTION LENDING AGENCY
[r 1 hereby affirm Nan there u a constroabon lending agency for to Performance of
CaInc work(err which Nu Permit is Wood(Sec.309?,Civ,C.)
WLender's Name
MA
.7 z Lcomes Address
V Q 1 coral that I have read this application and!sou Nu the above information Is
IL comaca i agree to comply with all city and county ordinances and sum laws slating to
U building conswmion,and hcmhy authorise represenuniva of this city to enter upon the
above-menuuned Pmpc ret for inspection which ms
(We)agree to save,indemnify and keep hamlas Ne City of Cupertino against
o-Fi rA mc,siacque gmcnR cosuudapcnseswhich may in any way accrue agunss Sud Ciry
V z inconsequence of Ne grantin6 of thispermit
ti APPLICANT UNDERSTANDS AND ALL COMPLY WITH ALL NON- DINT Issued by: Date
SOURC ULATIONS.
SignatureApp 0 AA imam a Re-roofs
H DOUS MATERIALS DISCLOSURE Type of Roof
Will li future building occupanssmre orbandlc harardou metrial
as defined by the upenino Municipal Code.Chapter 9.12.and the Health and Safety
seaum 255255320)?❑Yes ON. All roofs shall be inspected nor to an roofing material being installed..
If a roof is installed without first obtaining n inspection,I
Will the applicant or forum building occupant sax equipment or devices which g aagree to remove P
emir WaNnus air conuminanu as defined by Inc Bay Axa Air Quality Management all new materials r'0[inspection.
Disuim?
jfes ON.
I have read the haaardws materials requirements under Chaper 6.95 of the Califon.
.is Health h SafetyCode.Sccumu 25505,15533 and 25534.1 undersand thmifuhe building
dao rot curently have a leant duet it ismy responsibility m of,the occupant of the
xquireme wnchmuvbc . aanamleetufcasoraepen . SignatureofApplicant Date
Owner orauthorixdag t x All roof coverings to be Class"B"or better