03050158 CITY OF CUPERTINO *�»4,' T '°=`"�
BUILDING DIVISION PERMIT �C�NTRAC�T=QRTNF.OR TION:
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BUILDING ADDRESS: _ BATH ROOM INC, THE PE1M1T N003050158
22822
ER'S NAME: 1910 W EL CAMINO REAL PERMIT"SOST"0/2003
LAM WILLIAM G 2 AND PAMELA
PRONE: (415) 96B-7666 SANITARY NO. CONTROL NO.
ARCHI'IEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
loo LICENSED CONTRACTOR'S DECLARATION JbDescri non
01 1 h.reby grim that 1 un liaue� o
dcr provisions of Chapter 9(commencing � P
wh"Secdon )afDMatch 3 oflhaB neuend Pm(esslons Code,and my Im.om is
�7 mrnnm naerrtn B
BATHROOM REMODEL
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Deter ARCNTIECT « LARAY1017.Q tf-�B vII dP.�pawls`del
1 unaersund my plana shall W use u publle records
Lkcnwa Professional
AUG 0 1 2003
OWNER-BUILDER DECLARATION
aE a 1 thereby.(Sce Net 1 1 exempt from Nc Contractors Co e:Myer law for the g''� p�(�
ID0 whchfollowru,uresapettithucodun LgBuber,mpss and RvfdWulish." murmity orcounty BUILDING
$� which inquires•permit no eaNWe4 eller,i Applicant foram demolish,n mPalr any swcturo
�, Pnarwiu iuvenn.alwmquitetW,isiforamen refile a,signed(Char ant
se that(comeincing eJpurstion7 NcofDivisNarthe oftheBuacwssluenrclaw(Codc)or Sq. Ft.Floor Area s4\(a(gl®tion
Ric
that M Is exempt
Section and or Division r of al eged Business and Proon.Any
CMc)or
�.. Net W u exempt Nem(rom and the buts for Nn alleged exemption.Any violation of
Section 70313 by any appllcam fora penult subjects the applicant to a civil penalty of Occupancy Type
net mote than Bw hundred dollen(5500).
❑I,uownu of Ne proPestY•mmY emPloy.0 wird vnguu Ne'v suis rompeNatlon.
wid doff wort'.Cod Ne he Comi a rem s License
Law ltd ror Apply
W aa,wrier Of
urd ent,wh ons Code:The Conuacton,Liwue law dots not apply lf In owner is 10 2 - PIERS e 1 d Inspections
property whoeaWilds
pro provided
that
Improve who daeuneh work himself edthrough his
hOwn owever.thea,provior i Nat such ImprovementsAMnot..fcnrortneG roeuk If. 103 — UFER
builder the building orimprovementis sold wllhinone war ofImproeforNeowner-
builder will hove the burden of paving Net W did not build or improv for purpose of 104 - REBAR
'ale.). 105 — ANCHOR BOLTS
D 1,u owner of the property,am exclusively contracting with licensed contracwn to 106 — SEWER & WATER
construct Ne project(Sec.7W,Business and Profusions Code:)The ConmecwrS LI•
cove taw does not apply an an owner of property who Wilde or improves themen.and. 202 — UNDERFLOOR PLUMBING
who conaacufor such projects wird aeon icwr(s)licensed pursuant m me Contndofe
Lkens.law. 203 — UNDERFLOOR MECHANICAL
D l am exempt under Sec. ,B a P C for this ruson 204 — UNDERFLOOR FRAME
u Date 205 — UNDERFLOOR INSULATION
WORKER'S COMPENSWiONDECLARATION 301 - ROUGH PLUMBING
I hereby affirm under petalty of perjury one of the following aeclanlmorc -
❑Ihaw end will mainalne Cardilate of Consentwrelf-insure far Worketa Compcn- 302 — TUB & OR SHOWER
titian,u provided for by Sttaon 3700 of ate Labor Code,for the peri ormame or Lha 303 — ROUGH MECHANICAL
work for which this permit is issued. 304 — ROUGH ELECTRICAL
D 1 haw and will maintain Workce,Compensation Imummse,As required by Section 305 — FRAME
3700 of the labor Code,for the performance of the work forwhich Nu Permit is leaned.
My Warkcfs Com�ensNon Insurance rime�r ane.Policy number are:
306 — HOLDOWNS
Clr ,1 Sf1-C• ,Po1R!t�Nn: 'II�' ct k°I 307 — INSULATION
�`e( ERTIFICCOMPENSATION INSURANCE ORKERS' 308 — SHEETROCK
rmissection need nulWcampleted if be Permit Is for..hundred dollars(SIW) 309 — EXTERIOR LATH
n`I`"') 310 — INTERIOR LATH
I unify that in Re performance or the work for which this xmit t u issued,1 shall not 311 — SCRATCH COAT
employ any penin in any mannerso u w hum
o .+ubject to the Workers'Compensation
Lewsof California.Date 313 — ROOF NAIL
Applicant
NOTICE TO APPLICANT.If,after making this CcNOcam of Exemption,you should 501 — FINAL ELECTRICAL ENERGY
become subject in the Workers Compensation provisions of the labor Code,you most 502 — FINAL PLUMBING ENERGY
,J O forthwith comply with such provisions or this Permit Nall W deemed rewked.
z CONSTRUCTION LENDING AGENCY 503 — FINAL MECHANICAL EN
IWnby affirm Net Nen is.comlNctinn lendingapeney l'n,the perfurmsnee of 504 — FINAL BUILDING ENE
3 > the work for which this permit Is mantel(Sm.3097.Civ.Cd
Lend505 — FINAL ELECTRICAL
i[1 p ch Nun.
�z Lander:Address 506 — GAS TEST
v p 1 unify that I haw mad this application and sum that the above information is 507 — FINAL PLUMBING
F cmm 1.I agree to comply with all city and county Ordinances and sure Iaws relating to
mudw+
OU buildingcnuuction,andherebyauthorimmpretcnafthis city toentetuponNe FINAL MECHANICAL
above-mentioned propeny for Inspection porpotes 0 9 FIN
(We)agree to save,indemnify and keep hameleu Ne City of Cupertino against
p) liabilities,judgments.esu and expenses which may In any way accrue against Wit City I G
U z in eansegnencc or the granting of this permit.
.. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:5 WORKS Date
sou REGU TIONS.
n Re-roofs
u of Applin Date
HAZARDOUS
US MATERIALS DISCLOSURE Type of Roof
Willy t e Cu nniar future ipal Co e.Chapter
note orhandle Health a material
As OC Sec by the 32ad? a Municipal Code.Chapter 9.13,and Ne Health and Safely
.SCNes 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
[Dyes c®No
Will the applicant or future building occupant use equipment or dcviws which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants As defined by Re Bay Area Air Quality Management all new materials for inspection.
District?
Dyes (�kNu
Its
msd the hassrdrw+mawrials requirements underChapter6.95of tW Glifar
nu HmlN'SafoyCode.Sz.25505.25533and25534.Iundemand NuifNe Wilding
dans not comedy haw a tempt,Net it u my respoNlMlity w ramify tic aeeupant or the
In tswhkh !=mmcipriorwiuuanccoface ncateoroccu ver. Signature of Applicant Date
�+_Vl
Owner a euro sed agent AD D� All roof coverings to be Class"B"or better