03020028 Amok
CITY OF CUPERTINOpl x 1�'d.I
BUILDING DIVISION PERMI CO.'rNTRACTOR INFORxk�MA, <'
�.,'r
BUILDING ADDRESS: THE BATH ROOM INC PERMIT NO.
22881 LONGDOW
WNER'S NAME: 1910 W EL CAMINO REAL APPLICATION SUB DATE
TIM BROWN 02/07/2003
PHONE' (650) 968-7666
SANITARY N0. CONTROL N0.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑0Z
w LICENSED CONTRd under
DECLARATION
t; 1 hereby affirm that l am licensed under provisions of Chapter 9(commencing Job Description
¢ wiNSemian7000)of)ivisionJof NCBmin nand Professions Cade,endmyliceuc is
'r'?y in full( rad eRut.
zppz Lke �y( 71�L _Lj(y-�g2'1-. BA T IGHT REPLACEMENT
F_,:,o D —': n/ '� cnnvacmr_7NF(/Ell( Qde s+t ' � �
� Q ARCHITECTSBE�,1.AR rtT1oON
o6U lundcrsundmyptsnxshallheuxdTspuhlic e da
EccnFEB 2,5 2003
u_O xd Profcsmonal
OWNER-BUILDER DECLARATION
Sy a 0 p I hereby affirm that 1 t. exempt from be Contractor's License law for the �'I AING
a�tap0 following mason.(Section 7W t.5.Business and Professions Cudc:Any oily or county • �•
X m which rtquircs A Permit m cnnsuum,slier.;mpnwe,demulim.or repair any nrumrt
I—Zt poor to its issuance,also requires the applicant for such Permit o rile a signed suumem
p that M is licensed pursuant to the provisions of the Contractors Licenx Law(Chapter 9 Sq.Ft. Floor Area 10013ilatIOn
W52 (commencing wish Section 7")of Division 3 of she Business and Professiou Cadc)or
that he is exempt shemfmss end the basis for the alleged eaemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars($501n. 8r Occupancy Type
'[]I,uow,rcrof Ne pmpeny,or my employees with waguu Heir tole compensation,
will do she work,and the structure is not intended or offered for sale(Sao.7044,Business —
and Professions Code:The Conlreemea License Law does net apply to an owner of 102 - P I ERS eq=d Inspections
property who builds or improves thereon,and who dmssuch work himselfor through his
own employees,provided Nu such impmvemenu art not intended or offered for We.it, 103 — UFER .
however,the building or improvement;.xld within one year ofeamplelion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of 104 — REBAR
sale')' 105 - ANCHOR BOLTS
❑ stuct the pori Nc PropertSec.70y,amesineuadvely contrProfaufing with:)TheComcensed mmors to 106 - SEWER & WATER
won La the es noel(Sec.7014,Buineu end Professions Code:)IN Contractors nd
aux lawdnesnoupplymtn ithaof Properlywho seddsorant to to themon, 202 — UNDERFLOOR PLUMBING
who icamse acufor xchpmJecuwiNeconhaaor(UlicensedpunwnuotheContrxmrS 203 - UNDERFLOOR MECHANICAL
Lkenx taw.
❑ lu"esemptunderSec. ,B&PCforthiareuon 204 - UNDERFLOOR FRAME
wnet Dare
WORKER'S COMPENSATION pECI.ARADow 205 - UNDERFLOOR INSULATION
I hemby Aram under penalty of perjury one ofthe following declarations: 301 — ROUGH PLUMBING
❑l have and will maintain a certificate or consent to self-insure for Worket.Compcn- 302 — TUB & OR SHOWER
union.As provided for by Section 37W of the Labor Code,for she perfomaxame of the 303 - ROUGH MECHANICAL
work for 01hawand ill.paintiinWorkd. 304 - ROUGH ELECTRICAL
❑1 Nva end will maintain Workers ante of
w Insurance,h required by Section
7700 of she laWr Code,for Nc perfo,man<eof the work for which this Permit is issuW. 305 — FRAME
My Workers Compensation[mum"carrier OdPolicy
306 — HOLDOWNS
C :31-�.�C R"TIrC % NcFRA)MWKERS' 307 - INSULATI
ON
COMPENSATION
INSURANCE 308 — SHEETROCK
(Thu section,tW not be completed if Ne penult lsforonc hundred dollars($101)) 309 - EXTERIOR LATH
m iess.) 310 - INTERIOR LATH
I certify that in the Performance of the work for which this permit is issued,I shall not
employ any pclsan in my manner an u to become subject o lM Workro Compensation 311 - SCRATCH COAT
Laws of California.Data
Applicant 313 - ROOF NAIL
Laws
NOTICE TO APPLICANT.If.after making this Cemi fcate of Eacmption,you should 501 - FINAL ELECTRICAL ENERGY
become subject to the Workers Compenufion provisions of the labor Code,you mut
>OO forthwith cnmplywith Such pmvisions-1mi-Permits hall todecmcdrawlmd. 502 — FINAL PLUMBING ENERGY
q
CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
H
I hereby Aftirm that dicta is a construction lending agency for she Performance Of 504 - FINAL BUILDING ENERGY
C >
that work for which this permit isIsmail(See.309].Civ.C.) 505 - FINAL ELECTRICAL
G Q
lender's Name
z IanderaAddmAA 506 - GAS TEST
U O I anify that I have read this application and state than the above information is 507 - FINAL PLUMBING
l4 F correct 1 agree to comply wish all city and county oN;narxes and sum laws relating b
O U building construction,and hereby authorize saimusearmatinS of this city to enter upum the FINAL . MECHAN CAL
� W ehavcmemioned Property for inspection purPous.
F y (We)agree to tiara.indemnify and keep harmieu the City of Cupertino against 0 9 FIN 0
py
liabilities,judgments,costs and expenses which may in try way acme against uid Cdy Cj A NG
U7 in consequence or IN granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH IAL Issued by:5 WORKS Dat
SOURCE REGULATIONS.
AV/l
roofs
gtg'nawM 01Applma oatmctor ])am, Re-
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding Occupant store or handle b coudous material
As delisted by the Cupemino Municipal Code,Chapter 9.12,and die Health and Safety
ode.Section 25532(a)? )
C)Yes ZNo All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding ccupans use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit hatiom us air contaminants As defined by this,Bay Area Air Quality Management all new materials for inspection.
District? P
0 W 0%.
1 have mail she hauNous materials tequimmmus under Curer 6,95 of she Califor.
1
no Health&Safety Cole,Sections 25505.25533 And 25574.1 understand Bar if Ne Wilding
does not commuly have a knaalJihat is is my maponsi bil ity to nod ly the exi pant ol'thc
tcyjw�iryf�njenu wInch
�must bemetp riono iuusnce atact�atepf�oqu Signature of Applicant Date
Owner or ewhorind a
y.
'reagent pa,g All roof coverings to be Class "B" or better
I W
Q m
m o v E t d $
m � 0 _ trC3 qp
ag amo � �i c
a 3 W SUBMITTAL
U IF ME COR
a.
eta71003
J-2 Tp� {,p
gPPRO EO
S.�RDANCE WITH THE CITY OR
a, o0 COf S AN ORDINANCES
SIGNEDr_ _
This set of pia s a Id specifications MUST
oe kept on th, jo al a:l times and it is un
.d to Ira° .xv _Lanyes or alterations
it permission from
- , I:uaat6no.
o cJ m -.h,>tians
in
•M)esnn-,r -r Smtr. LPW
Pfd P > 2i
� mm0rD
$ m m — —
& ma
m a m m 10 ro
yoy ¢¢m ¢¢ c c
N .- cii °l V of (G
• NI dimemlone L gin detlpneb" This Is LII original design end mum Brown Scale;1/2 =1' Design: 02/05/10 DwO no.
,t given am subject to vebncebon on not be released ar copied unim Deb '. 02/05/100
Job ON end edtumment W nt job applicable fee has been paid orj ob
wndibone. order placed. Designer
Job Site:
( cS Mr.and Mrs.Brown
72661 Longdown Rd.
Cupertino,CA 95014
406-253-9007
c m 3
tr
gra
2 C - �OVJfIL
6�= y0* Work Performed By:
o The Bath Room Inc.
1910 W.EI Camino Real#E
Min.View,CA 94040
F 654968-7666
License#604922
Gµ�N
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n
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3 Scope of work:
° 1.Replace shower p W c Notes:r.= }
a Z Replace shower valve 1.Shower_valve is
3.Replace toilet rr1 pressure:hataroad
m 4.Replace vanity top and feu 2.Toilet is 1—i6-GPF
5.Install GFCI p 0 u
6.Install exhaust fen
m N
O r-
It m w o)
St 9
$'o
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ii
CITY OF CUPERTINO
CUPERTINO PERMIT APPLICATION FORM
0 2?
APN# Date:
. z — ?lb/�
Building Address:, .:,. .:.
ZZBQjI ( oNc��vin1 RD
Owner's Name: Phone#:
Mp.+ MSS. F3QpvJlJ 405 .253' 9'O
Contractor: License #:
THE PKA P-W c,. 60ggZz2,
Contact: Phone#:
Io50-9(�� 6b
SaddContrac r: _
g rmit Inf .
Elect lumb Mech
cription:
ntial: OD&(,� SITRAI&T R Commercial:
Sq.Ft. Floor Area:. $/Sq,Ft.:
ArchitectBngineer: Valuation:
• Type of Construction: Occupancy G oup:
uanti Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE -gldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
4BOILER2 Boiler> IOOK to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILERS 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
BCON ',TAXR 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 BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
1 of 3 0
4WS- 417
CITY OF CUPERTINO
BUILDING DIVISION PERMIT ;CO,,NTRACTOR INFORMATION
ITU I LDING ADDR ESS: THE BATH ROOM INC PERMIT NO.
22881 LONGDOWN RD 01020028
OWNER'S NAME: 1910 W EL CAMINO REAL APPLICATION SUB DATE
IL TIM BROWN 02/07/2003
"" (650) 968-7666 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
DO LICENSED CONTRACT'OR'S DECLARA'T'ION Job Description
U p 1 hereby(dthat 1 am licensed under provisions of Chapter 9(commencing P
�?tKml wilM1 Section]INNpol ontil
Division lir the Basin•ss and Pr fcsslnm Code,and my license is
�- fila it If I.g y>4 � Z L BATH REMODEL/STRAIGHT REPLACEMENT
Oz— D1e Cam�amect¢n�re FINAL
E®
f
I understand my plansshallM usCH ed pu�liRc rca�rJs Ov Yee
cad,
i LicenedProfemional FEB 2 t 2003
OWNER-BUILDER DECLARATION
¢`�<Z 1 hereby oilirm that I em exempt rom the CnmMmnr's License Law for the
a a 00 following reason.(Section 7031.5,Business and Professions Cmlc:Any city Or enunty
,2� which requires a permit to emoumt.idler,improve,demolish,m repair any shat"M
w—ta prior to its issuance.also requires the applicant forsuch permit to file a signed semmenl Ya,
that he is licensed pursuant to Ne pmvisinns of the Connector's License Law(Chapter 9 rt. Floor Area ,$1( Iyr�l00
(commencing with Section 7000)of Division 3 of Ne Business and Professions Gyle)or
ou thal he is exempt therefrom and Ne hasis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of or Occupancy Type
not more than five hundred dollars(S51N0. P y YP
❑I,as owner of the property.or my employees with wages as their sole compensation,
will do SO work.and theswaurc is nm intended to offered put.]a(Sec.]014.Bminess —
and Prefeaions Code:The Contractors License Law does not apply to an owner or 102 - P I ERS e(lulred Inspections
propcny who builds or improves thereon,and whodoes such work himself or through his
man employees,provided that such improvements arc not intended or offered for sale.If, 103 — U}-i'ER
however,the building or improvement is sold within one year of completion,the owner.
builder will have the arAen of proving Nat he did not build or improve for purpose of 104 - REBAR
sate')' 105 - ANCHOR BOLTS
❑1,m owner of the propert,,am exclusively contracting with licensed contractors to 10 6 - SEWER & WATER
construct Ne project Dec.]foal,Business and Professions Code:)The Conuanor's Li-
rimmLawdoesnetapplycoanownerof property who bodies orimproves lhereon,and 202 - UNDERFLOOR PLUMBING
Lho icense aw, moochprojectswithacmm�nm(s)bcenedpurauammtheCommnord 203 — UNDERFLOOR MECHANICAL
License Law.
❑ I am exempt under Sec. ,B&P C for Nis rcmun 204 - UNDERFLOOR FRAME
owner Date 205 - UNDERFLOOR INSULATION
WOR KER'S COMPENSATION DECLARATION 301 - ROUGH PLUMBING
I hereby affirm under penalty of perjury one of Ne following declarations:
"✓ haveand will maintain aCenificaeofConsent toseR-hvure for Worker's Conpen. 302 - TUB & OR SHOWER
aatinn,as provided for by Section 3807 of the Labor Code,for the performance of the 3 03 - ROUGH MECHANICAL
work for which this perme la iseprd. 304 - ROUGH ELECTRICAL
❑ 1 ave and will maintain Worked Cnmpthasom Insurance,as required by Section 305 - FRAME
3]01)of Ne labor Code,far Ne performance of the work for which this permit is issued.
My Workers Compensation brshonce career d Policy:hs her are: 306 — HOLDOWNS
Cath : S. F T. C. IieyNn.:-)Ij hChf iih9 307 - INSULATION
CIRTII TcATEoFEXEM IONFROM WORKERS'
COMPENSATION INSURANCE 308 - SHEETROCK
(This unbar need not he completed if the permit is found,hundred dntlare($100) 309 - EXTERIOR LATH
orlea.) 310 - INTERIOR LATH
1 certify that in the perfmmance of the work for which this permit is issued.1 shill not 311 - SCRATCH COAT
employ any petmm in any manner im as to become subject to the Workersmp
Coensmion
Laws of Calipurda.Dat`
Applicant 313 - ROOF NAIL
NOTICE TO APPLICANT:If.after Maki ng this Cmulicate 01 Exemption,you should 501 - FINAL ELECTRICAL ENERGY
become subject to the Worker's Compensation previsions of the labor Code,you must
0Z fonbwiNcomply wish such provisions orthis pe.it mall hedeemcdMwwd. 502 - FINAL PLUMBING ENERGY
Z0 CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
'7
C1 E1 hereby affirm for here is a construction lending agency for the performance of 504 - FINAL BUILDING ENERGY
?„
13) the work for which this permit is issued(Sec.3097.Co,C,)
an „rjQS — FINAL ELECTRICAL
Q Id,r's Namc
] Z 1<Odc'aAddress 506 - GAS TEST
J 0 1 cenify that I have mad this appliceion and state Nat the i e e information is 507 - FINAL PLUMBING
Fcorrect.l agree to comply with all city and county ordinances and start,laws relating to
�U building construction,and hereby authorise representatives of this city to came upon the FINAL MECHAN CAL
[1) shout(WO) greeed in aw,orty for inspection keep es.
>" tY (We)agree to save,indemnify and keep harmlcsv the City of Cupertino against 0 9 FIN
fF-t N liabilities,judgments.costs and expenses which may in any way accoue against said City 5 A NG
V 7 in consequence of the granting of this perm it.
G APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL NON-POINT Issued by:5 I WORKS Dat
SOURCE REGULATIONS.
xwnit/ WITH
Re-roofs
Signature of Applican onoactor .ter
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or future building smcupam store nr handle ba/ardous material
a defined by the Cupertino Municipal Code,Chapter 9.12,and the Hcallh and Safety
cam.Section 2553200? t All roofs shall be inspected prior to any roofing material being installed.
❑Yes AN.
Will the applicant future building Occupant use equipment or&vices which If a roof is installed without first obtaining an inspection, I agree to remove
70wner
aiardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
❑Yes �bI havead the har odem,ram,nalsm,mocusntsunde,Capw h95oHheCalifonealth&SafelyCeile,S,ctio'mr,2�5305,25533 xvd255M I understao!Natifthe building
nnott currently have a wousiLel it is my msprmihilily m nndfy the occupant of the
enlswhichmustC met poormiauanceofa cam rf0.'pupSignature of Applicant Date
�Jojr authorized agent ''_-I/ T Dam All roof coverings to be Class"Bur or better