03050158 (4) CITYOFCUPERTINO
BUILDING DIVISION PERMIT CgN=LI�AC' OR IIVFORMA.T " g
BUILDING ADDRESS: BATH ROOM INC, THE PERMIIN003050158
228
ER'S NAME: . 1910 W EL CAMINO REAL "'`""6" fS 0/2003
LAM PBWILLIAM G 2 AND PAMELA
PHONE: (415) 968-7666 SANITARY NO. CONTROL NO.
ARCHITECVENGINEER: BUILDING PERMIT INFO
BO ELECT O PLUMB MECH
O O
X00 LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm Nat I am licensed der provisions of Chapter 9(commencing P
with Section )af Division Sof Nessa and Professions Code,and my license la
^_N info]](c ne effect. 3 ,,,////// �L 22. BATHROOM REMODEL
Dean. o C g c r n T. 2 R .
ARCIiT EC' LARA— nTO� PINALED
; < �ItodcrsundmyphtrimmilWusc apubliciamods
Xo� Licensed Professional AUG 0 12003
OWNER-BUILDER DECLARATION
I I hereby affirm Not I am exempt from Ne Contactors License Law for the
i.0 O following rcuon.(Section 7031.5,Business and Professions Code:Any city or county
IS which requires a Permit to cmasuuci.altar,improve,demolish,ar repair any structure I IBM Mass..
—ZL^ prior in its issuance,also heroines the applicant for such Permit torile asigned statementarst.4—is
4`blID®tlOn
< Na heisliccnsed punuanlmNe pmvisiau of Ne Contnnah Liceuc lawlChaptar9 Sq.Ft.Floor Area $
$ (commencing with Section 7000)of Division 3 of Ne Business and Professions Code)or
— Nat be H exempt therefrom ad Ne basis for the alleged exemption.Any violadon of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of Dr Occupancy Type
not more than fiw hundred dollen(S500).
❑1,as owner of the property,or my employees with wages as lheirsele compensation.
wilid.th.work.,.d Oe.mcturti..ti.mndid or.Rercdfors le(Sec.7W.Businus tot — FOUND
d Professions Code:The Co sectors Liceose Law doe not apply lo in owner of 10 2 — PIERS
e 1 d Inspections
a
props ny w ho bullets or im proves thereon,end who does ouch wand:himself or through his
own employee,provided Nat such improvements art not intended oro@red forale.If. 103 — UFER
however,the building or improvement is sold within one year of completion,the owner-
builder will haw Me burden of pmoing Nat he did not build or Imprew for purpose of 104 — REBAR
ala). 105 - ANCHOR BOLTS
❑1,as owner of Ne property,am awludwly matimcting with licenced centrmmol to 106 - SEWER & WATER
construct Ne project(Sec.7014,Business and Professions Code:)The Contnclors Li-
cense Law doss not apply re an owner of property who Wilde or improv thereon,and, 202 — UNDERFLOOR PLUMBING
who contracts for such pmjmus with a contractor(s)licenced puremanno the Convacrofa
Liesnse Isw. 203 - UNDERFLOORMECHANICAL
❑I an exempt under See .B$P C for this reasen 204 - UNDERFLOOR FRAME
One, Dan 205 - UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION 301 - ROUGH PLUMBING
I hereby amen under penalty of perjury orta of Ne fallowing decimations: 302 — TUB & OR SHOWER
❑l haw and will maintain.Cenifeam ofConsanl loself-msum forworkarsCompao- 303 — ROUGH MECHANICAL
atian,u provided far by Section 3700 of the Labor Cade,fm ft performance of Ne
work fm aae
which this Permit isid. 304 - ROUGH ELECTRICAL
❑1 ban and will maintain Workers eompa sm on Insurance,as required by section 305 - FRAME
3700 of the Labor Code,for Ne performance of the work for which this Parrott is issues.
My Workcra Cam nation lnwnnce uricr ane Policy number are: 306 — HOEDOWNS
c�m'�r: 307 - INSULATION
�c
COMPENSATION INSURANCE
308 — SHEETROCK
(The section need notal complclod ifthe Permit is foram hundred dollar(SIM) 309 - EXTERIOR LATH
prim') 310 - INTERIOR LATH
1 certify Net in the performance of Ne work for which Nis permit is issued.I shill not 311 - SCRATCH COAT
employ any person In any manor an as in become subject to the Workers'Compensation
Laws of Califam&Date 313 - ROOF NAIL
Applicant
r NOTICE TOAPPLICANT:If,oflormtiongthis opincamorEecmption,you sbmuld 501 — FINAL ELECTRICAL ENERGY
become subject in the Workers Ccauro islion pmoiaions of the labor Code,you mus 502 - FINAL PLUMBING ENERGY
,Z forthwith comply with such provisions or this Permit shall W dcemed hooked.
za 503 - FINAL MECHANICAL EN
CONSTRUCTION LENDING AGENCY
rl Wmby affirm Nat Nem is a consronimn lending agency l'nr the performance of 504 - FINAL BUILDING ENE
z� Me work for which this pernitlsissued(Sm.3097,Ch,C.) 505 - FINAL ELECTRICAL
Gq tl Lenders None
z LandcrsAddroes 506 - GAS TEST
U p 1 ttnify that 1 hew mese this application and sole Net the above information is 507 - FINAL PLUMBING
4T. F correct.I agree to comply with all city and county ordinances and sure lewa relating to
U building construction,and hereby authority repmsentative of this city to color upon the FINAL MECHANICAL
F W above-mentioned propcny for Iupection purposes. 0 9 F I N
(We)all.e m saw,indemnify es tech hay in M tit City of Cupertino against
y
liabilities,judgments,coals indenify and loos mayilss Me City of Cupertino
sold City I (j
U in consequence of the gaming of this Perm it.
FG7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:5 WORKS Date <;4
SOUREGU ./,TION 5&111
16
Re-roofs _(7
Siret of ApplicaHAZARDOUS MATERIALS DISCLOSURE Data Type of Roof
Will Ne applicant or future Wilding occupant sore or handle haandous mammal
a do0ned by the Cupertino Municipal Code-Chapter 9.11,and Nc Wall,and Safety
`o de,section M532m)7 All roofs shall be inspected prior to an roofing material beim Installed.
❑Yea aNm P P Y g g
Will Ne applicant or future building necupant use cquipereat a,devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit haandnua air cone mm nu as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑tics
1 have real Nc basrNws materials requirementsunder Chapc,15M of the Califor-
nia Hculth&SafctyCode,Savom 8305,8533 and 8534,1 undenied Nat if Ne Wilding
it=not currently haw a tenant Nat it is my respamibility to amity the Occupant of the
ire mwhich ustbcmctprimtoissuanceareCCNncamofOccup cy, SignatureofApplicant Date
�tyJ^ /l �y_�/` L
ownero autthodradagen1 ti All roof coverings to be Class"B"or better
63 Job She:
Mr.8 Mn. own
. r T� lIsm
2262 Lino,CA 2 01
Cupertino,CA 96014
408.249-0739
5Hc?JE+2 F^"
Hz x 34
cu1t,T1A�E.o
Work performed MAY 0 2003
The Beth Room,In
EXNAu ST F^0 1910 W.EI Camino I#E
114"'A ML View,CA 94040 gy .
fLJOREs[£ 66ense# 0 -
UMHT L.losttss#801922
1
139 139 D
° =e panand
2.Replace shower valve
3.Replace toilet
• 4.Replace vanity,top,West
6.Install GIFCI
laf Q 6.Rspleos eA mat tan
YhPP OVEO
IN ACCORDANCE WITH THE CRY OR
BT
CODES I
INANCES
DAT
SIGNED _
This set plans and specifications MUST
trocar be ke on the job at all times and it is un
1.Showervalv4blpr?se!+!?.by?n?sd.ngas or alterations
69 2.Toilet Isl.B'&Fmo withnut wrimn permission from
3.Exhaust fee w nMoresent light
the D111101116 uapt., v,4 of Cupertino.
The stamping of th;�fit@n and specifications
SHALL NO( be 04 to permit or to be an
,pproval of tho i'xtptian of any provisions
.1 nnv C I� 0 rl.e Ae Or State law.
• Ao°Imwrlow erw NM 9W:IN•-1' oWpn:05=io owen
elwna weed w vwMnbm conn nN emn vied Olden W mut Oso : MM10e
job No and toMlob edWnNwwOaoophd unwr
COMM10ti appk�bM ps nw bwnwMorfes DMWwW
AY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM.� J� 0/6
CUPERTINO uI
APN # r Date:
s o3
Building Address:
2-Z82�'LoNtiDow 20.
Owner's Name: Phone#:
rn2. �- WrL5- rni�nr� 0`3-253- 073
Contractor: ,_ License #:
Contact: I Cupertino Business License#:
0(0
Building Permit Info:
Bldg Elect Plumb Meog<s
Job D, scription:
Residential mercial ❑
Sq.Ft. Floor ea: S $/Sq.Ft.:
Cost ofProje : Occupancy roup:
000 .
Type of Construction:
u rL,Er�C1t7EL,
Quantity Fee ID 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 BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
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Lt� J V r
Via` �Y OF CUPERTINO
CITY° PERMIT APPLICATION FORM
CUPEkTINO
Quantity Fee ID Fee Description Fee Group
BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI New Multi-Family Res MECHANICAL
BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL
BNEWMULTI Multifamily Res ELECTRICAL
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BNUMULTI New Multifamily Res PLUMBING
BNUSFD New Single Family Res BUILDING
BOVERTIME Ins ection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pblg Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP 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 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 cfin MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Fumace MECHANICAL
BREMFURNOV Relo Furnace> l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
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alO
CITY OF CUPERTIN
PERMIT APPLICATION FORM
CUPEI,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
BSPECIAL Special Insection 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 Issuance PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
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