00100004 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PHRMI'INO,
OWNFIVS NAME: APPLICAI'If.$CCj1L%LLb004
21005 LAURETTR DR
IIONI?: - SANITARY NO. Cq_ylgfly PLO.
MITCHNER, DALE @(@2
BUILDING ITEINIIT INTO
V ❑0❑ AHCfiITELT?:NGINr:EH: BLDG Ii1.r:C1' PLUMB hll!Cll
NUJ l-1 I_I IJ —'I
LICENSIiD CON'TRACTOR'S DECLARAIION
zt = 1harcn IfnmdontIamteen.sedunder fchntervtcmnmenein Job Description
C z_„ prat ore o p g
I TITS,
emu r�uiu)nr Droiwn,o a nl d,u n,oinrs.dna pnnb.JonF cone.and dor u.<n.e
<4- nm fun force aria ft t
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ce 3 a t- Dme DECL p A'T
ARCHI'I IiCIS UECh
' ARION
t=°� rondemlanntnyphmssbrllbeumdawIodide eve on], PANEL UPGRADE, c@@ RMP
a a.p C Licensed Professional '
OatI or RIID.UBRDIi he Contractor's
I berehy affirm or I am exempt Imtn the Can,mcmr'.v :Anye Low lin the
[-].� Iitldr ,ngaire,..(Sc..it ,7WI.S.R.m1c, andse,cssimas rolih.or Anychy or county
E O which reyuircs n permit m uimst e,applicant
improve,h Israel
e t file
repair any snueurc
c. poor h:r heits It...n ,farr,rcmd ,,msthmisions mh,rwehpenniuofileaeLarcd smunmm
— m:phui.ucenwrdmSectionTienmoiiski nrmeenmmemessand.cl.awou,C'ery Sq. FL Floor Area Valuation
Ica ing s eempttaneftern and
Ov mar thealeedexmpion,ProAny
Cndq
or S,,he is exempt coy amli t the halls fur the alleged exemption.Anod pennon
or See,mn 7031.5 iv any dred de,dollars( Ierndt wan,iccts menppherm m a civil penalty
nrnot more than fnehundreaanlmrwaslx». � APNNumbel' OccupancyT�yge
❑I, owner of the pmpi otiny employees win,wage.asmcir...le ,npen.a,ion.
w;R do he work,and the structure is not intended or ofered for.ale(Sec.Ana.
Be,inew.nil Prne'sions Code ire cnmmoto's uconsc Low does nor apply It,dot8uired Inspections
owner of property Who builds or improves thcmon,and who does.such work hinn.clf 32655@@ 1.•
or through his own employees.provided that such iinpro croal arc not intended or
olfured for laic. I.howuvur,the building nr iinpmvtown,is sold within one year of
completion'meownenunder„alhave,heburden ofprnv-ingmmhedid not build o,
improve mill o 304 — ROUGH ELECTRICRL
❑L as ow net of the pmpeny.run exclusively contracting x;th[icons cd eanlmmon n; 501. — FINAL_ ELECTRICAL_ ENERGY
LinNlreet the proj,,,IS,,t(ua,moanc5.and Pmawsiom cndI rhe C.na,.....s 5@5 — FINAL ELECTRICAL
cense Law doe.Dot apply,o air owner of prolIerty who builds or improve.,hcreme.
and who contracts for such projects with a cummcmgs)licensed pursuant to the
Commcmt's Liccnsc Law.
❑Lam earnipt under
}S,esr����(rY� / ,B•&PC dot suis....v
v •rc ON DE RATION
WORKER S COMPENSATION UL
I bruch,infiron andor In.inaIty ifpcj Y it he trtll sin,drolmonion,
1 1 Eric and will nallelsoR 11 Certificarc ot'C „ If' for Worker's
'ompc I n . pro don h el .by Section }Axl f 0 Labor Code. f the _ O/
pert .do r k fwhichtl issued,
❑1 have and w'II drainfain ta Compensation I c d by r inn
TI
5 MI f h I b Qat I pn pct t' the A hi do permit h 't in
tccu J Ml Workers C pc ,' Insurancecarrier and Policy nomm,are:
C.arn 1'oliuy No.:
CERTIFICATION OF li%GUPI'ION FROM WORKERS'
COMPENSATION INSURANCE: •
This section need not be complemd if the permit is bonne hundred dollars
(S 1x01 nr luws.l
I eenify that babe perfurn.fee of the nark fm which this permit is issued.1 ,
sh,Jl 1101 cinpiny only Inr>nn ,I any manner no,o to becmne.subject I,,he Worker, '
Compensation Lars of California.Date
Applicem
N(1TICE'f0 APPLICANT:IL alter nmking,his Certilicac ill Excuuminn.you should
becmne mIjec,to the Worker's Inmpenwtion provisions of the 1,bur Car,you must '
Q O b thw l III comply Is hh Inch fare kinds or this perch,shall he deenmd revoked.
Fr_Z+> CONSTRUCTION LP.NDING AGENCY 1 h..cny oftrnt hen mem t.n consmmllon Imtdmg agency bar me porriano cn
fiber work for x'hich,his permit is icvura(Sec.A%)].Civ.C.)
0. A Lendcr'I Name
.ti. Z Lcndcr's Address
V Q I croify that I hove rend this application and ua¢that the mese immunimmu is
mumu,1 agree m coo,ply with un cut,and county ordinances don slide laws remhng _
building c .t Iand hereby attforlrap tt xs of this cityt enter upon
6111 ,hconnive i d lao,rcoy lot unti,ectranpurpoIcs. .
'i. 0. (We)agreetindemnify dA harmless_ BeCity lCp.n est
Vi 1, den t. r. and e ' which may in tiny way accom against said � O �,C'NC ^/
City
APPLICANT UNDERSTANDS AND WIL OMPLY WITN ALL NON-POINT Issued by: Date
SOURCE RP ALAfi . � I/),f �Q/ Vl7
Sigm of Applicm,/Contvc Doc Re-roofs
IIA'LARUl,US MATERIALS II 'Ll15UItii
Wllth,a lieanlmrfuinrehuildingrccup:minomorhandlehvuN .sm
licentious Type of Roof
.o'defined by the Cupertino Municipal Code,Chapter 9.12,and the flcahh and Safety
GNr.Sellem pycs 255}2(a)'!
0N
All roofs shall be inspected prior to any roofing material being installed.
Willits, cant orIntent building oc,v,m1 soocrimncmordevice,11rieh If a roof is installed without first obtaining an inspection, I agree to remove,
mit bmarduus Dir comammoms as defined by the Ray Arca Air Quality Management
'r.v,ric,�I
eall new materials for inspection. Applicant understands and will cut with
Yes oNn all non-point source regulations.
I have read he hamnlons lumenal,requolle e s,tmlet Chopmr,h,09 of 111,
California I]eailh&Safety Cade.Senior,25505,25533 and 255}J.1 understand Lha
fill nodding dnes no curmn,ly have a tenon,,n 1,it is a,
my repmmid'"m notify doe
..Part of the m4Vimmccns xamh midst ne , itaor,o islwce of a Cctllfcale m
Occupancy' Signature of Applicant Date
tf�t� (o vJ .
i,.m agent )-- Dam All roof coverings to be Class"B" or better