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05090132 (2) CITY OF CUPERTINO BUILDING DIVISION PE R CONT RACTORINF,OOR ON BUILDING ADDRESS: THE BATH ROOM INC PERMIT NO.O 5 O 90132 10160 EIRWOOD DR - OWNER'S NAME: PERMITLSSUEDATE KARIM SHARIF 1910 W EL CAMINO REAL 09/20/200S ONE: SANITARY NO, CONTROL NO. (650) 968-7666 ARCHITEC(ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH uO0 LICENSED CONrRACTOR'S DECLARATION Job Description wu C 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing P U with Section?M)) rDRisim.3 oftLe Busincssaad Professions Code,. mylimmais P iafullfmm.adefinet Eo 2 MS BATH REMODEL jg_ License Class .�3 ZUOMa nFtl Dale `TSD car T 7 / d A CHITECI-S DECIARATIO R—Sof-"` Y W U l understand y plans shall be used as public iecomos lee, goG Licensed Professional r 3 OWNER-BUILDER DECLARATION 1 hereby affirm than 1 am1. exempt from the Contractors o License Law for the �t\ so o which me reason.(Section IDD L5.Business andmpr ve.d soli Cole:Any city or ectomy V $10000 ire which requires a permit m cnnstrucL eller,improve,demolish,m repair any structurt -'ar prior to its ismance.alsu squirts the applicant forsuch Permit o Rlc a sigacdstammcm � 26 thathcislicensedpersuanitotheprovisionsofMeCaron ur'sLicenselsw(Chaptcr9 Sq.Ft. FloorArea CJ> Valuation y1- (commencing with Seed..7000)ofDivision 3of the B usinessmd Professions Code)ur i`§ that he u exempt therefrom add the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a potion subjects the applicant to a civil penalty of r Occupancy Type not mom than five hundred dollars($500). - ❑h as owner of the pmpeny,or my employees with wages as their sole compensation, will do the work,and the sm emas is not intended m offered for sale(Sec.7044,Business and Professions Code:The Commencer License Law docs not pply to an owner of Required Inspections property who builds or impmves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale.If. however.Re building or improvement is sold within one year of completion,Ne owner, Wilder will have the burden of moving Nat he did not build or improve for purpose of salt.). I,as Owner of Re property.am exclusively contracting with licemed convectors to construct the project(Sec.7044.Business and Prafessiotu Code;)The Cmtramor's Li- st'law docs not apply to an owner of property who builds or improves themed.and who contracts for such projects with a eonvaeums)licensed pursuant o the Conuacmr's License taw. 1 asn exempt under Sec. .B&P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one Of the following declarations: I haw and will maintain a Cenlfcam of Consent to self-insure for Workers Compere setion,m provided for by Section 3700 of the labor Code,for Ne performance of the -work far which this permit is issued. 1 hoe and will maintain Workers Compensation Insunnce,as required by Section 37W of the Labor Code.for the performance of the work for which this permit is issued. My Workers Cornin,...tioo Insurance carrier and Policy no bcr,am: "blCartier. "C S olicy No.: ' COMPENSATION I N FROM W K RS' COMPENSATIONINSURANCE (Thu section need net he completed if tie permit is for one hundred dollars(SLW) icssm) 1 minify that in the performance of the work for which this permit is issued,I shall oat employ any Person any manaran as to become subject to the Workers Compensation Laws.1 Calif..its Dale Applicant NOTICE TO APPLICANT:If.after making this ccni imic of Eaciamion.You should become subject to the Worker s Compensation provisions Of the Labor COM.you muse .JO foMwilh comply with such provisions or this farm it shat l W deemed revoked. z CONSTRUCTION LENDING AGENCY t-.lin I hereby affirm that there is a construction lending ageney for the performance of a 7 Re work for which this permit is issued(Sec.3rh)L Civ.C.) [t7 0 Lender's Name Z Lender's Address C.)0 1 modify that 1 have read this application and sate that the above information is I, (•-' correct.1 at to comply with all city and county Mid...ves and sum laws relating m 0 U building construction,and hereby mdmnm refecsentatim,ofthis city to enter upon the r W above-mentioned property for inspection purposes (We)agree to save,indemnify and keep harmless the City Of Cupertino against y liabilities.judgments,costs and cxpcnus which may in any way accrue against said City U Z in consequence of the station oft i;permit. '—' APPLICANT UND AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REG ATI e' Re-roofs Signature ofA li M/Co a or Dam HAZ OUS MATERIALS DISCLOSURE Type of Roof they li or future building Occupant store of handle hazardous material as def d by the isfammo Municii Ode.Chapter 9.12,and the Health and Safety COMO.Seaion25532(a)7 All roofs shall be inspected prior to any roofing material being installed. ❑Yea Will the applicant or future building Occupant use cywpmmt Or devices whim If a roof is installed without first obtaining an inspection,I agree to remove emit hazardous air ccmmminamu az dcf9MI by the Bay Area Air Quality Management all new materials for inspection. District' [I Yea I have read the terminus materials mquircments under Chapter 6.95 of the Califor- an H.]it&Safety COdc,Sections 255(1 533 and 25534.1 understand Ra ifthe building dors not currently have a m t, tis my responm hility to nod fy the o cupant of Re requirements whit 3p rprior a of a Cemficam of acupmty. Signature of Applicant Date Ownerm _oriraJag Dam All roof coverings to be.Class "B" or better CITY OF CUPERTINO �m 1 of 1 PERMIT RECEIPT OPERATOR: conniew COPY # 3 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 34235028 . 00 DATE ISSUED. . . . . . . : 09/20/2005 RECEIPT # . . . . . . . . . : 31279 REFERENCE ID # . . . : 05090132 SITE ADDRESS . . . . . : 10160 FIRWOOD DR SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : KARIM SHARIF ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2662 RECEIVED FROM . . . . : THE BATHROOM CONTRACTOR . . . . . . . : TOORAJ HASHEMZADEH LIC # 22324 COMPANY . . . . . . . . . . : THE BATH ROOM INC ADDRESS • 1910 W EL CAMINO REAL CITY/STATE/ZIP . . . : MT VIEW, CA 94040 TELEPHONE . . . . . . . . : (650) 968-7666 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL - '----- --- -- - ---------- ---- - - - --- ---------- --------- - --- ------- ---- -- ---- BPERMFEE VALUATION 10 , 000 . 00 169 . 56 0 . 00 169 . 56 0 . 00 BPLANCHK PERMIT FEE 169 . 56 226 . 28 0 . 00 226 . 28 0 . 00 BSEISMICRE VALUATION 10 , 000 . 00 1 . 00 0 . 00 1 . 00 0 . 00 BENERGY PERMIT FEE 169 . 56 81 . 39 0 . 00 81 . 39 0 . 00 ELECTRIC SQUARE FEET 48 . 00 3 . 84 0 . 00 3 . 84 0 . 00 PPLBG SQUARE FEET 48 . 00 3 . 84 0 . 00 3 . 84 0 . 00 EPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 MPERMFEE SQUARE FEET 48 . 00 3 . 84 0 . 00 3 . 84 0 . 00 MPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 TOTAL PERMIT 604 . 86 0 . 00 604 . 86 0 . 00 METHOD OF PAYMENT AMOUNT NUMBER ----------------- ------------ ------- ----------- CHECK 604 . 86 1124 ------------ TOTAL RECEIPT 604 . 86 • •r V3 N N o .a c $ • o f �m oa E 0 O U (p Q rD 0 L 'eon m cn mm-o° moo ; Qj jy c � m= m ?,Q nta t c mn1, sm> ,3ii �i 0 0 0 0 U O 0 aaaaa 01 0 0 0 , til (A¢¢¢ Q¢ C C m I s J� 0 • s 1L r i � b a O M � X ID M Sharif Scale:maximum Design: OB/13/10 D g no. All tllm re subject c co Co callorlonv Thinor is ml origaselnel designpie and unless must Date : W/1WIO gNen are sublect to ent Heft jo on not be blle feed or been unless lob site ns. adjustment to fit job applicable fee has been peltl or lob contlitlona. order plecetl. Designer 00 Ib - *CITY OF CUPERTINO CITY OoF CUP O PERMIT APPLICATION FORM OF APN # Date: Building Address: Mailing Address (if different from building address): 10160 irw �( Owner's Name: Phone #: Contractor: License#: Contact: Phone: dyu lei;-7666 Cupertino Business License#: Fax: zir �9�vG Building Permit Info: Mq3 jt2 Q ti�yt �YiO EL Bldg Z' Elect Plumb 21" Mech 0� Job Description: (2ep lace , oa tic � e Jr Residential 8' ef�S i-:,+ Commercial ❑ Sq.Ft. Floor Area: 48 s�Y- n� )1Fq.Ft.: Cost of Project: T— Occupancy Group: �UIUUb . GG Type of Construction: Please check this box if the project is a second-story addition: ❑ ro'ect Size: Standard ❑ Large ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL 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 Elee 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BEWESTIGA Investigation fee BUILDING # 3Iz7 � lof3 a Ld CITY OF CUPERTIN40 CITY OF PIT APPLICATION FORM CUPERTINO Quantity Fee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum . PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pblg Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINI'ERCEP 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 rinklerBackflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain &Vent PLUMBING BPWATER Iastatl/Alter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUAJBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMAIltHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BRENU URN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace> l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREME"MOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non-Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL AiL BREMRESAPP Remodel Res Appliance ELECTRICAL 2 of 3 0"% *TY OF CUPERTINO � CITY OF PERMIT APPLICATION FORM . CUPERTINO Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Sips, 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 BSPECIAL Special Inspection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp 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 PLLONGRNGC Planning LR Comme/ Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Change BUILDING • 3of3 CITY OF CUPERTINO BUILDING DIVISION PERMIT 7CONTRACTOR�INFORMATION,s3 BUILDING ADDRESS: THE BATH ROOM INC PERMIT ND05090132 1 OWNER'S NAME: PERMIT ISSUE DATE KARIM SHARIF 1910 W EL CAMINO REAL 09/20/2005 E: SANITARY N0, CONTROL NO. (650) 968-7666 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 uoo LICENSED CONTRACTOR'S DECLARATION mF I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description ZW with Section 7000)of Division 3 of NC Business and Professions Code.and my license is n„ inrwlmBeanderrea MS BATH REMODEL >qz License Claes '3 Lle,g 9049Zz F tj Date Co...,'S DEC +n sl ARCHITECT'S DECI.kRATI�� -i (understand y plans shall he used as public accords /�[wr /j s o� Licensed Professional 5 OWNER-BUILDER DECLARATION <I I hereby alio that 1 am exempt from Ne Contractor's License Law for the oO following moon.(Seed..713IS,Businessand PmfCOinm Code:Any city or county <2 f which requires a Permit to construct,alter,improve,demolish,or repair any structure $10000 d20 prior to its issuance.also requires the applicant for such Permit o file a signed statement < that the islicensed puawanitothcpmvismisoftMCamrxmr'sU. claw(charter9 Sq.Ft. Floor Area Valuation x�th (commencing with Section 7000)of Division 3 of the Busioas and Proressiom Cock)or i $ that he is exempt therefrom and the basis for But alleged eaemption.Any violation of Section 7031.5 by any applicam for a permit subjects the applicant to a civil penalty,of not more than five hundred dollars(X500). r Occupancy Type 0 I,as owner of the property,m my employees with wages as their to compensation, will do the work and the swaum u not intended or offered fo Ole(Set.70 a d,Business Required phiovi and Pmressiore,Code:The Contractors Liccme Law does not apply te an owner or q properly who builds or improves thereon,and whodoessuch work himselfor Borough his owncmplduem,pingor i pr sue ens is oldwit in ne intended ora@red for owner,hon /RI �sidey qNe Wilding orimprovcmcnl is sold within one yearof completlon.Ne owner- {vf 'builder will have Ne burden of proving that he did not Wild or improve for purpose of .'Y saaJ. ❑1.as Owner of the property,am exclusively contracting with licensed committed;to ,5�� construct the project(Sce.7044.Business and Prmechom Code:)The Comracteri Li. !� cc...law docs not apply m an owner or Droperty who builds or improves thereon,and, 7005 who contracts for such pmjeas with a epnt ammos)licensed pursuant to the Convector's a. License Law. BUIL ❑lore exempt under Sec. ,B&PC for this reason rim Owner Date WORKER'S COMPENSATION DECLARATION I hereby afftmt under penalty of perjury one of the following declarations: I its and will maintain a Cenifcam of Consent to self-insure for Worker'sCompen- sadon,as provided for by Section 3700 of Ne Labor Code,for the performance of the work for which this permit is issued. ❑1 baro and will maintain Workers Compensation Imuran,as acquired by Section 37W of the labor Code.for the peROm dso of the work for which this permit is issued. My Worker'.comp�eynsationn Inssu�ntncit under and Policy n ram: Cartier. `// ] —wL(��7a olicy No.: CERTIFICATE OF EKEM ONFROMW K RS' COMPENSATION INSURANCE (Thu.,it.need not W completed H the permit is fm m m hundred dollars(SIM) or IC.1 I ccNfv that in the performance of the work for which this permit is issued.1 shall net employ any person in any manner in as to become subject o the Worker;`CompemNon Laws of California.Daae Applicant NOTICE TO APPLICANT:If,after making this Cenificaa of Esemption,you should become subject to the Worker's Compensation provisions of the labor Code,you must fetthwlth Comply with such provision or this permit shall W deemed mvokcd. Z O CONSTRUCTION LENDING AGENCY 'TIN I hereby aft,.Nat there is a sc mlmctinn lending agency for the Performance of a Bic work fur which this permit is issued(act.3097,Co.C.) W 0 Lender's Some Icnderi Address z U 0 1 cenify Nn I bars mad this application and sate that the above information is fy F Correa I agree to comply with all city and county ordinances and state laws Bidding to 0 V Wilding eonswetion,and hereby mdumine mpreaenutiws of Nu city m enter upon We r a above-mentioned property fm i ore ction purposes. (We)agree to save,indemnify and keep harmless the City of Cupcnino against rFa rA Rabilities,judgments,cosa o andexpces which may in anywayideruc againstsaid City en V Z in consequce ofthe grand, oft permit. APPLICANT UND AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCER ATI Re-roofs Signazum afA nUCo or Date /y t HAZ OUS MATERIALS DISCLOSURE Type of Roof ��y(AI Nem li Lir future building mcupan Soe of handle ha,wdous man:rial as derg{¢d'by the u.or e floo Mum'cip t,Chapter 9.11,and the Health and Safety Code.Section 25531(a)? �,[J All roofs shall be inspected prior to any roofing material being installed. ❑Ye 0Will the applicant or future wilding nupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove ,ha ardous air c.n amina.is u dcf9cd by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes I haw mad the wardnusmateriab Bquimmena under Clapter 6.95.fthe Califor- niaHut"Safety Cade,Sectim 25N5,IV33 and 25534,I underazarW thmifthe Wilding does not Currently have e te n isy mmossidoi y to notify the asupmt of the requirements �.r ohenficeteofOceupancy. Signature of Applicant Date Owner or mind ayDate roof coverings to be Class"B"or better