05110021 CITY OF CUPERTINO °"" * „q,,ex :mx '` ` ""
BUILDING DIVISION PERMIT 3COfVTRAC;TUR TNF.ORMATION
BUILDING ADDRESS: PERMIT N0.
10684 CULBERTSON DR
OWNER'S NAME: PERMITISSUEDATE
JAMES & SUZANNE PIGULA 04/03/2006
NE: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+00
LICENSED CONTRACTORS DECLARATION Job Description
4 V1 hereby.note de
that 1 am licensed unr provisions of Chapter 9(commencing
i whhSectionTOM)ofDiAsionSofgoneBusinesesandProfusionsCode,andmylicemcis DEMO (E) HOUSE
n< In full forte and affect.
j Z Licence Clan Lk.g
3 Date Con DECL
ARCHITECTS octal ATION
I undersand my plans shall In,used An public semoa
5 G Licensed Profcaional
OWN ER-BUILDER DECLARATION
ga I hereby affirm that 11. exempts an Inc Cafflo-hr'sCol License Law for the
i G t following moron.(Section]ansto Business and ft.demolish,
Code:Any city or county $10000
$ which sets han a permit re enmtrueL alter.impmw,h pcmit t Of minor any struclum
-ILa shed em iuiauance,aluu equlee theApplicantof for the Couto mitrofdea Law(ed stskment
E (annoucingwJpStatiolmNepmrisisiu3offt usinssaLanscltw(Chow)or Sq.Ft.Floor Area nation
a�$ (commencing with Saxon 7000)of Division 3 of theeged Carand Prof ea Vi Chow)or D
.. that he u exempt therefrom and the basis far the alk{M eamptlan.My Waladon of
SeMan 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of nm ter _ CC.dIiMCy Type
not mare than five hundred dollars(5500). I \
1,an owner of the property,m my employces with wage.as their sole compen,allan,
will do the work end dw aclum la not intended chaffered for ule(Sm.70M,Business Required Inspections
and Profusions Code:Tho Commutes License law data not apply e an owner of q P
property who build,or improves thereon.AM who does such work himselfor through his
own employes,provided IMlsuch improvements am nothwarlded oroffered for We.If,
however,the Wilding or Improvement is mid within am year of completion.the mvner-
Wilde�ill lam the Widen of proving that W did not build or Improve for purpose of
As
❑I.as owner of the property,am uclWvely contracting with licensed contractors,to
construct the project(Sec.7044,Business and Profession Code:)The Contncmr's Lb
mune Law docs not apply of an awnr of property who Wilds or harrows,thereon,Md.
who contracts for each projects with a conuacter(s)licensed pursuant in the Contractor',
License Law.
❑lam and Sec ,B R P C for this moron
131w!n
u Date 3 06
WUNIVERS COMPENSATION DECLARATION
I hemby affirm under penally of perpmy arc of the falldwing declarWon:
1 Wve and will malnuin ACenlOnm of Covent ro self-insure for Warkce-Compen-
n,an provided for by Section 3700 of the Labor Code,for the performance of the
for which this permit is Issued.
haws and will maintain Worker',Compensation Insurance,u requited by Schon
of the labor Code.for the performance of the wods for which this permit is amm,
Worker',CompenadonInanmnce carrier and Policy number are:
rrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Cnas section oeM nothecomp cted ifthe permit Is form WMreddollan($100)
or Ica.)
I candy that In the performance of the work for which this permit is laced.)&hall not
employ any'personina anceran kba[a u 'at tlWor en' ompenadon
LAW s of Cali(omi&.D
Applicant
N0T7CE TO APPLICANT:If.dier making this C Nfine of Exemption,you should
became subject an the Workers Cwnpensaoon provision of the IatwrCode,you muss
.7. Z forthwith comply with such Provision or thin permit shall W dcemM Owens.
ZO CONSTRUCTION LENDING AGENCY -
[..r.�. 1 hemby M.that Nen u a.Mebacti n,leading agency Car the perfurmana of
fY,r7 de work for which this Permit le Paced(See.3097,Civ.C.)
~n. Landers Name
0.. z Lander's Addmv
U O 1 omify that I law rad thin application and sue the the show information 4
H correct I agnea m comply with all city and county ordim noes mui sue laws elating to
O U Wilding construction,and hereby authmin mactemadvas ofthis city to enter upon the
LU about-mcmiaced property for impaction purposes.
(We)agree in on,indemnify and kap harmless tui City of Cupertino against
y Ilabiliticajudgmena corn and expenses which may In any way acerae agaiNlaid City .
U In consequence traming of this Permit. V(�
APPLICANT,41WERYINDS AND WILL COMPLY WITH ALL NON-POINT Issued by: 60 Date
SOURCER ATI �- �l 6'
11- Re-roofs
Signature of Appli 4&OURIOntracter
ARDOUS MATERIALS DISCLOSURE DW Type of Roof
Will she applicant or future W tiding recommisroe Or Mark,haandous material
a dented by the Cupertino Mu icipal .Chapter 9.12.and the Health and Safety
Cade,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes c
Will the applicant or future Wilding upon use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It havAnlous air mutual. u def y the Bay Arca Air Quality Management all new materials for inspection.
Istria?
❑Yea ONO
I h.sad the Won dons materials requ iemcros vole r Chapur 6.95 of the Csli kr-
nisl4alth@SaferyCode.SeMw25505.25533W25534.IandcrttsMthniftie Wilding
des not curie y haw a tenant that It is my rapomlhility m modify the occupant of the
requinmcn icnmr�ty�9ptpriormiauanceofaCard71111"awil Signature of Applicant Date
owner or
3 Darn All roof coverings to be Class"B"or better