05010009 CITY OF CUPERTINO
BUILDING DIVISION PERMIT C01�i f"GTORANFOItMATIO..N -
BUILDING ADDRESS: BATH ROOM INC, THE PERMIT 11%5 010 0 0 9
10343 NOEL AV
r OWNER'S NAME: PERMIT ISSUE DATE
THEODORE OLSEN 1910 W EL CAMINO REAL 01/03/2005
. E: - - SANITARY NO. CONTROL NO.
(415) 968-7666
ARCHITECTIFNGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
Lop LICENSED CONTRACTOR'S DECLARATION
y w I hcrcpY aaftfirm Nes 1 am lucnaed under p,'.��,,_'�'(a�'ods of Chavwr Y(ammcnring Job DCS u �
�< with ScaiosrZOBfy}of DivWo.3.f the Busad.n PrdfUWmd C.&.mdd.y Hcenxis Ikh - - _-
intulltortea Rett 6�j��2 BATHRM REMODEL (1)
5 M Z Loon-C1ua Lac.I -
z-q Da¢ Conor JG a...-. -
€W ARCHITECT'S T _ FEB 2005
wU 1uMc my plass shall he used as pWdicapgp14s7
o.
0t; Licensed Professional �I II rI a� R,6 If
3 OWNER-BUILDER DECLARATION Ise[ II II 8
.� I I looeby affirm Net I am exempt from she Conlncrors License law for dm ItraY"}/d U BR Rta}Y
Q0 following reason.(Section?031.5,Buslaess and Profession Calc:Any eily m emnsty
E$ff which requires a permit m c. I.alley,improve, m
dcnli bpai
,a,repair arty evuctulc $8000
I
-a prior m is issuance.also requires the apylianl for such Permit to Glc a signed nawment
izcthat heiahcensedpursuanunmeprovislamofthe Comm<ror,uaynmuw(chapter 9 Sq.FL Floor Area Valuation
y1-$ (commencing with Section]000)of Division 3 of the Business and Professions Code)of
Nasi he a eaempl lMrefrom and the hoof far has alleged eumption.Any vulauon of
Session 7031.5 by arty applicant fora permh aubjecu the applicanno an.civil penalty of
not man than five hundred dollars(550K)). e - - Occupancy Type
❑I.uowmr of the pmpcny,amy employee with wagers their sole compenudon,
and Professions ons code:The Contrumr, ndwha Law dao nal hinum f an ower is - Required Inspections -'
ownenywho s.provided
met at Sudeacon,a.dwhn doessSmmuNwork hinaselredWaugh his
howemployee,pmvidr. Improvement
thatvemech ntpsmid witsamnd year ded conspifem.for samme.It.
however.the Wilding or imProponving ma within oite year or completion,the ower-
builder will have she WNcn of proving Nal W did not Wild or improve for purpose of
ukJ.
❑1,as owner of the property,am exclusively conweling with licmued cooracmea to
convect the project(Se.?O1a.Business sad Professions;Code:)The Conusclors Li- -
case law does not apply to an owner of property who Wilds or improve thereon,and
who contracts for such projects with a contracmra)licensed permanl in die Contractors
License law. -
❑Iameaemptu.dcrSee .B&PC for this reason
Owner Data
�. WORKERS COMPENSATION DECLARATION
1 Mmby andm under penally of perjury ane of tiro following dmlention: _
I have and will maintain a Canifno¢of Cmuensm'elf-inum for Worker's Comi c.-
m,ion,as provided for by Section 37W of the labor Code,for the performance of the
orkfo hic"s pcdoi isieucd. -_..
w 11. and will maintain Worker's Compensation Insurance,u occurred by Section - -
TMc labor Code,for the performance of the work for which this permit is issued. ... ._
My overs ,.1.di Insurance canis and Polis member am:
c p cYG(9tG9
CERTIF1( FE%EMP�'1 FROMWOMERS'
QOMPENSATIOfl N,URA,
(Phissenion recd out W compound if,W prom,is f.roe hundreddoBam(SI W)
or Ice.)
I Mot that in the performance of the work for which this remain is issued,l shall not
employ any person in any manner an as to Weome Subject o lW Wortms''Compewdon
Laws of California.Data
Applies.,
NOTICE TO APPLICANT:IL after making this Cenificaw of Exemption.You should
become subjm,to the Worker's Compensation provivons of the lahnr Calc,you mot
.,O forthwith comply with such Provision Or this pemait shall W deemed raveled.
z try CONSTRUCTION LENDING AGENCY
(~ thereby affirm data there is a construction lending agency]or the Performance of
!Yi the work for which the permit is issued(Sec.3097,Civ.C.)
aA Lenders Nam,
=z Lender's Add.
V C) 1 cenafy Net I have read this application and show that ape above information is
f-+ conett 1 slide in comply with all city and county ordinnccs and sum has misting to
pU building construction.and hereby amhudm mprecnuliva of dus city m enter upon the
14ahove-mertioned property for bureaion purposes.
6. (We)agree to cove,indemnify stdkep hay in an the City of Cupms,uagarol
pl Ianbiasemtfutum
judgments,cors and ea penewhich may an any way sone again)said Cary
UZ kcon .gSof ANDWI. Issued by. Date
^ APPLNDS AND WILL COMPLY WITH ALL NON-POINT
SOURON
m Re-roofs
US MATERIALS DISCLOSURE Type of Roof
umm building median,start or handle hvardow material
ufared by the Cupertino Municipal Code.Chapwr 9.12,and the Health and Safety
1.Co $c y.25532(a)? t���y' All roofs shall be inspected prior to any roofing material being installed.
Ye /y3pm
�\vV If a roof is installed without first obtainingan inspection,I agree to remove
Will the applicant or future Wilding=upset sac equipment or devices which P
W.haaardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes t�rlNda�
I have mad the havNnu�s materials mquimmcnu under Chapier6.95 of Ne Califor-
niallalth&Safmy Cade,Seetion 25505,25533 amo2553a.1 understand died afore Wilding
Joe not X.ml, 4 chat it h my raponihili .til' mcdomc,tivintWmel iaadaeYdr.Gertifiamcr. Signature of Applicant Date
O,vD,w All roof coverings to be Class "B"or better