04080071 CITY OF CUPERTINO .,�'•=� '.% r'r '**+' "d< d" " " �`
BUILDING DIVISION PER CONTi2AC OR INF®RM�ON.,
� �a'th=�aew *..� e�t � a,ar ^ '
BUILDING ADDRESS: THE BATH ROOM INC PERMITNO.04080071
OWNER'S NAME: PERMIT ISSUE DATE
ZONE:
SANITARY 0 OL NO.
ARCHmB-CT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEDIA
l�
net,
LICENSED CONTRACTOR'S DECLARATION
y w g I hereby arfifm Nm 1 am licensed under provisiy s�of`Chapter 9(Commencing Job Description
EQ with Sceti IDUU)or Divivon3ofdeCBusinesaandFffifaaslurs Codc.and my license is
'_�„ 1n m1 eandcrrcc r zT REPLACE SHOWER/DOORS
p Z Lice Claes La a
O DdIC ~
Contra ha
~ r + 1
'y J '9CHITECT�DECLARATI N
m-+ s-t,TOCrsu y play!.Shall nsasLd as panhL records
Dau r
u G Licensed Procam al
OWN 1 DER DECLARATION
y 1 hear,.!Firm dem 1 am exempt from the Comment's License Law for the
spo followingmsson.(Seedon 7031.5,Basimaxand Professions Cade:Any city or county
y m which requires a pmmit to ennetrr mmq improve.demolish,or repair any structure
priors its issuance.also rectums the applicant for such Permit o file a signed sutemcm
< that he is licensed puraim,tothe provisions Ofthe ConvainnsLiceneeLaw(Charter 9 Sq. Ft. Floor Area Valuation
co (commencing with Section 7")of Division 3 of the Business and Profterinns Code)of
i - Na W is exempt NCmfmm and Be basis for she alleged exemption.My violation of
Section 7031.5 by any applicant for a permit 511bjoou the applicant to a civil penalty of 3(ATN0`lL�tgr0 0 Occupancy Type
nos mom Nan five hundred dollars(S500).
v,
cl I.as owner or the p.,a,.or my CmPldyCC.with wages az tncir.mle compan-tion,
will do the work.and fire stations is not intended or offered for safe(Sec.704a,Business Required Inspections
and Professions Code:The Conaacmers License Law does not apply to an owner of q p
Owncnywhobuilroor iimpovuchirop and who does such work oroffeed for toiris
ownemplayeo•provided pr suchimprovements his Cod ear ded ofror.Rend for-lino-
however.Neawd sera improvementissold within one year of mprove fn.the puawns• !/
bullar will Mss Ne Gorden of proving that he did not Wild or improve fm purpose of q/s
❑1,as Cam r of Ne propert,am exclusively conmairig wide licensed contractors to v
tensan am project(Sec.7044,Business and Professions Cade:)The Contacmr's Li /
sense law does not apply roan owner of pmpcny who Wilds or improve Ntmon.and
who connotes for such pmjCcU with a contractor(.)licensed pursuant to the Conaamori /
License Uta.
O 1 am exempt under Site .B&P C far this mazon O�
Owner Date
WORKER'S COMPENSATION DECLARATION
1 Wmby affirm under penalty of'do,Sae of tW following declexxians:
I have and will maintain a Certificam of Common t0 self-insure for Worker's Cumpem
-tion,as provided for by Section 37M of dee Labor Code,for Ne performance of the
work for which this permit is issued.
1 have and will maintain Workers Compensation Instar¢,as required by Section
37M of are Labor Code,for the performance of dee work far which this permit is issued
My Workefs Compensation Insurance Vanier and Policy number are:
caner: q1 3 — 686f Polies Z: S� r
CERTIFICATE OF EO(EMFTION FROM WORKERS'
COMPENSATION INSURANCE
is aeetims need nm beeompleted if fle,permit is forone humlrod dollars(3110)
or less.) .
1 certify that in the performance of are work for which this Permit is issued.I shall not
employ any person in any manner ser az to become subject to NC Workers Compensation
Laws of Califomia.Dam
Appilcant
NOTICE TO APPLICANT:if,arm,making Nis Ccnificam of Exemption,you should
become subject to the Worker's Compensation provisions of the LaMar Code,you mut
.J O forthwith comply with such provisions or this Permit shall be dmmcd revoked
Z CONSfRUCT1ON LENDING AGENCY
[-i lbemny affirm Natdmmis a mumuchort lending agency for the perfamdnmuf
Poi 7 the work fur which this permit is issued(Sec.3(97.Civ.C.)
{tJ Q Under's Name
_,z Undcr's Address
V Q 1 ceni(y Nat I Ma mad this application and sum Nu the above information is
Conan.l agree to comply with all city and county ordinances and sum laws reining to /
�[J
building
(We)taction.and he¢bonnify dlitc,euntatmathewS this ofC.Iy to mrupantnc
W abovcdamommcd pmpcny far inspeNUn purposes.
(~W (Wes)agree to save,indemnify and keep harmless rite City of Cupertino egai it
Iiabilitiu,judgmcnss an
,Cosd expcau s which may in any way amroe aCainsuaid City O
U z in consgoenee of,lo, ling f this permit. Date
APPLICANT UN SEAN S AND WILL COMPLY WITH ALL N POINT Issued by:
SOURC ION (t v
Re-roofs
SigS AyrA ilea Co nor Dam
RDOUSMATERIALSDISCLOSURE Type of Roof
Will a applicant or rums building occupant store or handle harardaus material
as defined by the Cupeninu al Cod"Chapter 9.13,and the Heo1N and Safety
Cade,Section 25532(a)? y' All roofs shall be inspected prior to any roofing material being installed.
E]YCs
Wal riteyr,lBantor future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit Ali hazamnus air comaminRlU aydcrined by the Bay Area Air Quality Management all new materials for inspection.
Mit
d Ycs
I have read Nc haxardnus maerials aquiamens under Chaptor 6.95 o(the Califer,
ria Hal"Safety Code,SCNans 25505.35533 and 35534.1 understand that if Nes building
docs not cunend . n.m.Nat if is an respomihiliny b noulj IW ctpmt or One
fui mtssW i:Iriarni.aameeonceniBLamora`up Signature of Applicant Dale
me All roof coverings to be Class "B"or better
Owncrf out ri'rnd est arc
• CITY OF CUPERTIN#
acilyo PERMIT APPLICATION FORM l
CUPERTINO
oZp e-� o v J
• APN # Date: GG
Building.Address
20--1- ZU
Owner's Name: Phone #:
I-A L
Contractor: License#:
Contact: Phone#:
vu� 4�`✓ SG 13£�G 2
Applicant/Contrac.pr:
Buildi Permit Info:
Bld / Elect Plumb Mech
escription:
Reside Commercial:
Sq.Ft. Floor Ar. . .. $/Sq.Ft.:
Architect/Engineer: Valuation:
Type of Construction: Occupancy Grou .
Quantity FeIrID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX. Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC1000 Elec 600V <= 1000A ELECTRICAL
BELEC1001 Elec 600V > 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee I BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
1 of 3 Q
l �0
• CITY OF CUPERTIA
SCITYOF
CUPE TITNG PERMIT APPLICATION FORM
• uanti Fee ID Fee Descri tion MELECAL
ou
BMITIGATR Res. Housin Mit Fee G
BMNEWMULTI New Multi-FamilyRes ICAL
BMNEWSF&2F New Sf&2F Res RIA-- ICAL
BNEWMULTI Multifamil Res ICAL
BNUCOMME New Comm Electric CALBNUCOMMM New Comm Mechanical ICALBNUCOMMP New Comm Plumb INGBNUMULTI New Multifamil Res INGBNUSFD New Sin le Famil Res INGBOVERTIME Ins ection Overtime G
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE PbIg Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINIERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Plan Check Add Multi BUILDING
BPLANCKREP Plan Check Repeat Fee BUILDING
• BPREPIPE Re i e Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinkler/Backflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER Water HeaterNent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units<= 10,000 c&n MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREM 3USWAY Remodel Buswa s ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace> l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Lk aratus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE I Pole/Platform Fixture ELECTRICAL
2of3
P17"YOF17
CITY OF CUPERTINO
PERMIT APPLICATION FORM
CUPE TINO
Quantity Fee ID Fee Description Fee Group
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING.
BSEISMICRE Seismic Fee Res BUILDING
BSF&2FAM Single &2 Family BUILDING
BSFNA Single Family New Add BUILDING
BSPECIAL Special Insection BUILDING
BSWIM Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Temporary Bldg Permit BUILDING
BTEMPSVCS Terhp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electrical sq foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
3 of 3
The Bath Room, Inc.,
• ' Kitchen & Bath Remodeling Show��
1910 W. EI Camino Real#E a Mountain View 4040
Since t979 (650) 968-7666 FAX (650) 968-2151 Lic.it,t22
www.thebathroominc.com
rl g a r 8
= Om n 0 > 0 a me
.S
�r a$ 3 0 o m o o'1 Rci ans ¢¢ 2 ii-
1� NED
I�f`f OF CIORTINO
6PAWMENT
•
APPROVED
IN ACCORDAN 1F WITH THE CITY 0
CUPER� 'JD c i NC S
` x
li]
N:i E
o
1'„w et of plans and specifications MU• T be
k, , on the job at all times and It is ur lawful
t :ce any changes or alterations on same
o :;ritten permission from the B ilding
.m, City of Cupertino. }
of this plan and sped tions
an
i,CT be held to permit or to on
9
;'Ile violation of any p as of
a j.,.nanca or State Law. O
• 6*in d"Out �.
NI dlmemiab bm
This h en arglnel dsalpn end Must :maximum Design:
given are subject to vwlllcatbn on W be released or ccpled N. Dab : 07/21/1(Ni
lob alb a adluaanmd to M lob applicable be ho been paid or jab
. order placed. Designer
CITY OF COPERTINO ' ' a " " vg;
BUILDING DIVISION PI✓RMITCONTRACTOR INFORMAT ION -A
BUILDING ADDRESS: THE BATH ROOM INC PERMIT NO.
04080071
NER'S NAME: PERMR L4aUE DATE
12
ONE:
TERRY LAT I gin W PT CA.MINQ SANITARY 0 OL NO.
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
0 0
um, LICENSED CONTRACTOR'S DECLARATION
w C 1 hcrcby affirm Nn 1 am limnxd under No is, of Chapter 9 P mornmeing Job DescrifINALED
O whose! n7")oroi iaionJor NC Busi„eb anaP ore Code,and my rcroso is
mmb eanderr«t. z� REPLACE SHOWER/DOORS
�rz Lic Clava v Co." SEP Z 2004
� Date d Conuacmr area
be SAM][CHIT
CT$DEpublic or&
� a-+aNEcrm�Dl/y(s sh>II/Sgufcd u public¢cords
YyV / T
;pG Licensed Profinial BUILDING
3 OWN DER DECLARATION
1 hcrcby affirm Nat I em exempt from Toe Cnnuacmfs Lieenm law for the
00 following mason.(Section 70316,Business and Profc,siom Code:Anycity or county
K m� which requires a permit to construct,alar.improw,demolkeh,or repair any structure
w—'^ prior In its homance,alsu requims mb+ppllaant forsuch Nnottio rile a signed statement
EE' that he is licensed pursuantmLim previsionsoftheContractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
'FG (commencing with Section 7000)of Division 3 of the Business And Professinm Corm)or
y $
that K is exempt therefrom and the basis for the alleged ctemption.My violation of .
Section 7031.5 by my.,pii.,I.,.Permit ubjccts the Applicant o a civil penalty of 302NftVIber00 Occupancy Type
oat more Nan five hundred dollars($500).
t.as ownu ofine property,or my employees with wages as their able compensation.
will do the work And the mom"O"is not intended or offered for sale
(See.7014,Business Required Inspections
and Pmfessios Code:The Comructo's Limner Law docs not apply w u an ownof q p
progeny who build,or improves hom on,and who does such work himselfor through his
own cmployces,provided that uch improvements sae not intended or offered febaam.IL
however,the building or improvement is sold within one year of completion,the owner.
Wilder will have the burden of proving that he did not build of improve for purpme of
sale.).
❑1,AS owner of Ne prepeny,am exclusively contracting with licensed contractors to
consumer me pmjea(sec.7044,Business and Proboomns Code:)The Comrxcwr's Li-
no law docs not apply in an owner or perp rty who builds or impro,ca tim.s.And.
who cantracs for such pmjecs with a conuvcror(s)licensed pursuant a the Contramorl .
ns
Licee Law.
1 am nempt under Sec ,B h P C for this mature
Dam
WORKERS COMPENSATION DECLARATION
1 hereby aiTum under penalty of perjury one of Ne following declmnions:
I haw and will maintain a Certificate of Consent to self-insure for Workci sCompen-
ration,AS provided for by Section 37M of the labor Cade,for the performance of the
work for which this permit is issued.
I have and will maintain Workels Compensation Insuranm,az required by Section .
37W of the tabor Code,far me pcAonmana of thn work for which Nis permit ls issmd.
My Worker'sCompensation lnsunncejams,and POI icy numk,A:
carrier: 113 ^fiyy/6Fb f Policy :
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thuscctiaa Med not becomplcmd if me pemtit is foronc hundred dollan($101)
,it le.i)
1 certify Wt in Ne peduonanm of Jo,work for which this permit is issued,1 shell not
employ any person in my malmcr sea AS to become subject to 0k Worked Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT.If,after making thio Canincaa of Exemption,you should
become Subject in the Writer's Compensation provisions of the Lahm Code.you must
,,O forthwith comply with such pmvisinos or miS permit shall ktlecmN revoked.
Z CONSTRUCTION LENDING AGENCY
'r. I kmby affirm that there is a construction lending agency for the performance of
a 7 me work for which this permit is isimd(Sec.3097.Civ.C.)
W Q Lendcr'S Nae
G Lendm
er's Addmsa
U O 1 certify that I haw mad this application and sera that the show information is
W P cornier.l agree w comply with all city and county onlin mors and sure laws resting to
0 Wilding construction,and hereby authorimmpr ammudws hamolmserft orisc fCupmoy to rupnn rte
Y'� sbow-mcndoncd property for Inspection purposes
0. (We)agree w Saw.indemnify and Imp harmless Ne City of Cupertino agvml ///'''
rN Iimithm"judgmenu.costs and expenses which may in any way seemcagainst mid City / U O
U incormaqueuscafinegrantin fthie permit. *( Date r
.. APPLICANT UN STA AND WILL COMPLY WITH ALL N -P INT Issued by:
SOURC ION
e/ Re-roofs
Sig fA lies Co Tar Dam Type of Roof
BOGUS MATERIALS DISCLOSURE yp
Wi eapplicam or future building mcupanI Stove or handle haaamuus material
AS defined by Ba Cupertino��+un��meeaaI Code.Chapter 9.12,ate Oa Health and Safety
c,Section 25532(,)? X' All roofs shall be inspected prior to any roofing material being installed.
Yes
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
Ire,
t hvallous air eonuminapu aSQc'Rncd by me Bay Ama Air Quality Management all new materials for inspection.
s��Yes
1 he.mad the havaNnus materials requirements under Chapter 6.95 of the Califer.Health&SafelyCodeSmvom25505,25533and5534.1undcrmarwmmiftic building
snotcunenti a tenant, rithmy resNnsihilitywnotifyNe cuPantofNe
nimmen ic nark 'primwiavanmofaceidfimtebro, SignatureofApplicant Date
All roof coverings to be Class"B" or better
err rimd co, ate