06100150 CITY OF CUPERTINO �t
BUILDING DIVISION PERMIT
BUILDING ADDRESS: GOFF DEVELOPMENT & DESIGN t5t�'ITNO-06100150
21887 WILSON CT
PERMIT ISSUE DATE
OWNER'S NAME: ,
(408) 441-8076
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
p p LICENSED CONTRACTOR'S DECLARATION Job Description
V I hereby affirm that I am licensed under provisions of Chapter 9(commencing
z with Section 7000)of Division 3 of the Business and Professions Code,and my license is
�m in full force and effect. REVISION: STRUCTURAL ROOF FRAMING SOUTHWEST SID
Date Contractor
License Class Lie.# ORIGINAL PERMIT #05100055
Da
ARCHITECT'S DECLARATION
i a< I understand my plans shall be used az public records
)yU
u E" Licensed Professional
y� OWNER-BUILDER DECLARATION
> 1 hereby affirm that I am exempt from the Contractor's License Law for the
no following reason.(Section 7031.5,Business and Professions Code:Any city or county
e V which requires a permit to construct.alter.improve,demolish,or repair any structure
Z} prior w its issuance,also requires the applicant for such permit to file a signed statement
e=G that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Va$t®18 5 4 0
j t— (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5500). 32649018 . 00
❑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(Sec.7044,Business Required Inspections
and Professions Code:The Conuactoes License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
,as owner of the property,am exclusively contracting with licensed contractors to
co ct the project(Sec.7044.Business and Professions Code:)The Contractor's U.
ccnse Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑I am exe t under Seo. B&P C for is ren
Owner Date to
WORKER' COMP E ON ECLARAnON
I hereby,affirm penalty of perjury one of the following declarations:
I]I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Workers Compensation Insurance,as required by Section
3700 of the labor Code,for the performance of the work for which this permit is issued.
My Warker's Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
1 certify that in the performance of the work for wh'ch this permit is issued.I shall not
employ any person in any manner e b'ctto the Workers'Compensadon
Laws of Calif, �o
Applicant rr r t�
NOTICE TO A11PUifANTIr.after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
zforthwith comply with such provisions or this permit shall be deemed revoked.
z . CONSTRUCTION LENDING AGENCY
H1- 1 hereby affirm that there is a construction lending agency for the performance of
GY,> the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
=z Lendees Address
U 0 1 certify that 1 have read this application and state that the above information is
w correct.I agree to comply with all city and county ordinances and state laws relating to
Q U building construction,and hereby authorise representatives of this city to enter upon the
a above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
'Ft to liabilities,judgments,costs and expenses which may in any way accrue against said City L
U,'z in consequence of the granting of this permit. Date `'4���z 7
�-+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N7-3dan
POINT Issued by:
SOUR ULATIONS. �---t
Re-roofs
Signature o Applicant/Con tort ate I T of Roof
DOUS DISCLOSURE Type
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
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
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District? ,���
❑Yes
1 have read the hvardc/ws matrials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1
understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
requi nus which mastissmamce of a Ccrtiftcat of Occup . Signature of Applicant Date
3•
All roof coverings to be Class"B"or better
Owner or authorixcd a nt Da