05110022 CITY OF CUPERTINO �`�
BUILDING DIVISION PERMIT g�,C0 TRACTORtINFOR11fIATIgN :
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BUILDING ADDRESS: SANTA CLARA VALLEY CORP PERmTNo.05110022
0684 CULBERTSON DR
OWNER'S NAME: PERb9T I55UEDATE
JAMES & SUZANNE PIGULA 715 N 1ST 12/20/2005
NE: SANITARY NO, CONTROL NO.
(408) 947-1100
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�oo LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm that I am lianeed under provirm oof Chapter 9(commcmo
inj
with Section 70110)ofDivislon 7 of the Business nd Professions Cade,and my licemue Is
in cull force andertec4 SFDWL-2 STORY (24101 LIVING)
8: License Clan I.M.0 Contractor
DaGARAGE-420 '
0 te
ARCHITECPS DECLARATION
1 understood my plana MW be used as public words
` U
5p�3 Licensed Profesuanal
OWNexemptER-BUILDER DECLARATION
E 0 1 rumor ,farm o n I e1.,exempt from she demons Co License Law for the
i O o following reamn, emit t 71151.5,Buaw.sland ws.de Professions Code:Any oily or manly
$ which its issuance.
s•permit re exa«ass ft,alar,improve,demolish.t or repair ed structurerent
that he its iensad pursuant a6 in ret lM applicant o thefor such permit micensle ae ow(Cha mens
a Nnheislimnudtion7 NcpmviWonenflhcConncrostLccnusionChepkr9 Sq.Ft.Floor Area Val$540310
SCB den(cohea examwiththerefrom and sh basis 315 of the BusLsedemandon.Any
Codc)lir
T— dal he u exempt therefrom and she bob for Me allged exception.AnY Notation of
Section 7031,5 by any applicant for a permit objects the applicant to a civil penalty of APN Number Occupancy
not more Nan five hundred dollars($500). 37534025 . 00 Type
0 I.u owner of die property,or my employees wish wages as lith me campewtion,
will do she work end the almCYure is not intended oraQend for saW(See 7W.Business aired Inspections
and Profenlons Calc:The Cannanore,Limner law does nal apply to an owner Of q ns p
propeny who buildsor improves demon.and who Madames work himself ar tluuugh his
own employees,provided that such Improwmemstre not Intended moQeled forsaK IL a
however,the building lir improvement issold within am year of completion.Me owmr-
header will haw she buNem of proving that be did ml build or Improve for purpose of / 2U�1
oak.). !--2,/
.as now of the property,am exclusively contracting with licensed eonbacton to
caman=Lo she dean
(gee.7044,Busiweer of and Professioy who ui Code:)The Conuamon. rad BUILDING
cense law doer noupply to m owner of propeny.who Wilda or improves thereon,and, '
who conLaw.for such pmjecm with a cormactorb)licensed pursuant toshe Conlnmor'a
Lkena ave.
❑lam gas funder See .BkPCfor this noun
�Ql)
Owner 5A_n. Dau
VORKERS COMPENSATION DECLARATION
II hereby affirm under penally of pedury am of she fallowing declanlions,
1 haw ane will..loam•Cetificau of Comm bull-Insure fm WarFe/s Campen.
., as provided for by Section 5700 of the Leben Code.fm de performance of Ne
work for which this permit Is bused
0 1 hew and will maintain Workers Compensation Issuance,as required by Section
5700 of Nc labor Codd.fm the performance of the work for which this permit is intend.
My Warless Compensation hosanna artier and Policy numWr am:
Caller, Policy No.:
CERTIFICATE OF EKEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(Isis uctim recd Iwthceompleud If the permit is foram hundred dollars(SIM)
or less.)
I unify Met in she performance of de work for which this permit Is issued,l"I not
employ any person in an m C�r 9y4m�c rale rased la to Worker!Gam naadon
Laws of Calira.,m[��a�In §§}rennqqq,,,,�(I"L_ j p`
Appliunl�xY f -
NOTICE TOS UCKKKNNN'ITT':If,after making this Certificate of Exemption,you should
become object 0 de Worker's Compensation provisions of de Labor Code,you sun
.J O forthwith comply with such provisions or this permit shall be rimmed walked.
e
Z" CONSTRUCTION LENDING AGENCY
[•+ Ihenby affirm that ft.is.conoucdm lending agency ren the perfurmenee of
fYi ria she work fur which persnn Is in d IS=Civ.C.)
6W.Q Lender's Name P-IN�af ) •
= z Ieader't Md.
U Q 1 certify that 1 haw read this application and sou that the show information is
14 Fcorrect.1 agree to comply with all city and county ordinances and sate laws relating to
Q V building construction.and hertby aushoru mpreunmives of this city on maker upon de
tri aWve-mensioned property for Impaction purposes.
G (WO agree to an,indemnify and keep harmless the City of Cupenino against
I,) liabilities.judgments,costo and expenses which may In toy my accrue again,said City
O 7 in consequence of do graining of this permit.
r7 APPLICANT UN TANG AND WILL COMPLY WITH ALL NON-POINT Issued by: Date —Zp_
SOURCE REGU TI NS. `
9 12 -10 05- Re-roofs C7f o!
sisnature oappl2rhucomillichor Dau 'fit
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will she applicant or fumm building o cupmua
tmere or handle hrdous material
as de0ned by de CupeNno Municipal Code.Chapter 9.11,and the Health and Safety
code,C]Yu 25532(a)? W,(__ All roofs shall be inspected prior to any roofing material being installed.
Will the applicant lir future building occupant use equipment lir devices which If a roof is installed�without first obtaining an inspection,I agree to remove
117z.-Iiicr
I hnamnua air mmamimoumdcfinc by the Bay Area Air Quality Management all new materials for inspection.
uicR
0 Yu u
I hew road the huardmumaterals requirements underChapur 6.95 ofthe C45for.
Health&SafetyCode,Snedom25505.35555cad25554.1unMnmMthaifde building
s mAcurrently howaunu4shatitbmyponsibilllymmmurdeomupmtofde' notswhich abemetpriortoI""ofaccr67-yrSignature of Applicant Date
2All roof coverings to be Class"B" or better
on orator a Date