04070179 (2) CITY OF CUPERTINO a� �.y ��s�s �^s TT'
BUILDING DIVISION. PERMIT kCONTI ACTOR M� A A
.""DING ADDRESS: THE BATH ROOM INC PERMITNO04 0 7 0 17 9
22954 LONG DOWU RD
NE0.'S NAME: PERMIT ISSUE DATE
BARBARA MARTIN 1910 W EL
NE; SANITARY NO. CONTROL NO.
(650) 968-7666
A CHITECf/ENGINEER: - BUILD INC PERMRINFO
BLDG ELECT PLUMB MECH
y o p LICENSED CONTRACTOR'S DECLARATION e p .T� �
1 hertby affirm that I em licensed under provisions of Chapter 9(commencing en\®$�
withsectiannfD'iq.ion 3oflAc Busincev tib Pr Fssiunc Cude,andmylicevc is
^ � in cull force feet.lli/ —Jl/Gh~l`t-(f'(1J Z^C3i MS . BATHRM RE
j$ License CI Lic.lr
Dab Gamnmm AUG 3� 1004
ARCHITECTS DECLARATION
,l''i �tPdtt IensghallMuaed see puhlicrg[a/tla BUILDING
iO J Lic soI hem nal L_
3 OWNER-BUILDER DECLARATION
Ea f 1 hereby.(firm that I am exempt from Ne Contractor's License Law for the
OO following mason. (antro o 7031.5,Business and ere,de Professions Cando:Any city or county iz$ whichniirequires..a Permit re cores the albq improve,h Permit t or repair any structure
thepri,nnits tensed amalso nt to the
oivial.applicant for sucContractor's o file a
gned Law(Chapter
��6 (commis license]pSectio 7 the of Division 3 oche Business
Lironac Law(Chaprer9 Sq.Ft. Floor Area Valuation
Ila (cat he is(commencingwithSection?000)of Dosis n3 nttheegedexempton.AnynaCtion Of
lb`, Net he Is exempt oc¢fmm and the testi for the alleged exemption.Any violeGon of
Secjlon 7031.5 by any applicant for a penNt subjects the applicant to Advil penalty of Or 0 Occupancy e
not mom than five hundred dollars($500). P y EYP
❑1,ea owner cribs property,or my employees with wages As their sale compensation,
will do lhcwork and the stmctum is not intended or offaretl fors.1.(Sec.7044,Business
and Pu feasiana Cadc:The Contractors License Law docs not apply b an owner of Required Inspections
Property who builds Ids or im proves oeroon.and who d oma a uch work himsel f or thmugh his
own employees,provided that such improvements are not intended oraRered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving oat he did not build or improve for purpose of
.1,J.
D I.as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Profession Cade:)The Contractors 6b
cause law doas not apply to an owner of property who builds or improves themon,and
who contracts for such pmjacho with a con meter(s)licensed pursuant the Convectors
License Law.
D l am exempt under Sec. ,B&P C for this meson
far Dab
WORKER'S COMPENSATION DECLARATIONI hereby aflinn undernalty of perjury one of the following declarations:
have and will maintain a Certificate ofCanseen(to tilt-insum forWarkeb Comperen.as provided for by Section 37011 of the Labor Code,far the performance of the
for which this permit is issued.
1 have And will maintain Workers Canerm"S lOn Insurance,as required by Section
37W od&labor Code,for the performance,of the work for which this permit is issued.
My W Ca motion Insurance cam.or and Policy number am:
Cartier. Policy No.:
CERTIFICATEOF EMPTIONFROMWORKER '
COMPENSATION INSURANCE
(This acctirin need not be mOr plemd if the permit is forme hundred dollen(SIM)
or loss.)
1 certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner an as an become subject to the Workers'Compensation
Law.of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Cenifiatc of Exemption.you should
bacome subject to the Worker's Compensation provisions of the labor Code,you must
.J,Z
forthwith comply with such pnw sJmts or this pare((shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
Thereby affirm that there is a construction lending agency for performance of
Ci 7 the,work fur which this permit Is issued(Sec.3097,Cih,C.)
WQ Lender's Narm
4 z Ladcr's Address
U Q I certify that I have rad this application and sole that the above information is
LL E" correct,I agree to comply with all city and county oNinances and sob laws relating to
QU building construction.and hereby auomiaa repmsonolives of this city At enter upon the
4i1 altave-mentioneJ Profanity for inspection PurPOWL v
y (We,)agree Its raw:,indemnify and keep bemless the City of Cupertino against
tea h
liabilities,judgments.casts and expcmes which may in any way accrue against aid City
fJ Z in consequence of the granting of this Permit.
APPLICANT_LINDERSTXNK AND WILL COMPLY WITH AL NON OINT Issued by: ate
SOURCE REGg6igpoNs.
V, Re-roofs
SSignatureofApplicant ntraccr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building=upon,store or handle hazardous material
n defined by the Cupertino Municipal Cade,Chapter 9.11,and the Health and Safety
ado,Section 25532(e)7 All roofs shall be inspected prior to an roofing material being Installed.
❑secs - Nu P P Y g g
Will the applicant or future building accupam use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazaNaus air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
Dishlct7
Dy. Nu
1 have mad the hazardous matelots 5533 mdcnts under Cha mdffi5otthc Wilding
nia Health&Safmull,ho AScJliom155115smynoprait34.1...Orteuif the building
Jaa not�Nly how a ens Net it is my responsihility m nodly(he,occupant of one
"men us mel pdonoiasuace ora Ccnif¢ab af0c ufa cy. S ignature of Applicant Date
w on agent Oa
All roof coverings to be Class"B"or better
CITY OF CUPERTINO *3a'* '^y �`�
BUILDING DIVISION PE.' V�kY4xCIX a
BUILDING ADDRESS: THE BATH ROOM INC PERMITNO04070179
22954 LONG DOWN RD
NER'S NAME: PERMITIBEUE DATE
BARBARA MARTIN 1910 W EL
E: SANITARY NO. CONTROL NO.
(650) 968-7666
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
0 0 0 0
iOZ LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
L` wihllIn"an]011lleal. Sof He Business antlPrufcesiunsCode,endmyliccnscis FINALE®
tomo roreeu rent. ` C Licerean Cl
MS . 13ATHRM' REMODEL
d f�
Data Contractor
CHITECTS
z < �, nd.Ind Jin laps shall ..ti es pduli=N
-� �- AUG 3 0 2004
Z C Lice scq Prtdd�i nal
OWNER-BUILDER DECLARATION
Sqg: I hereby Maso affirm that 1 1. exempt from the sonsCContractor's License Law for he
`O� following mason.(Secdun](131.5,Business and Professions Code:Any city nr county
K$� which requires a permit ren con.mucl,eller,improve,demolish,or repair any structure
:a—w pdono its issuance.also requires the applicant forsuch permit to rile a signed statement
in.he is licensed pursuant to the previsions of the Contractor's License Law(Chapter 9 Sq,Ft.Floor Area Valuation
y+tst� (commencing with Section'i0o0)of Division 3 of the Business and Professions Code)or
i 3 that he u exempt therefrom and the buil for to alleged exemption.Any violation of
Segion 7031.5 by any applicant for a Permit subjects the applicant to a civil penally of
not more than five hundred dollars($500). oT Occupancy Type
I,as owner ofine properly,or my.mpki em with wage.m their sole compensation,
will do the work and the swctum is not intended or offered for sale(Sec.TYA,Business
and Professions Cade:The Comactar's Lieenu Law dam not apply m an owner of Required Inspections
property who builds or improves Hereon,and who does such work himseifor through his
own employees,provided Net such improvements are nat intended or offered for sale.If,
however,Ne building or improvement is sold within one year of completion,de mener
builder will have the burden of proving Het he did not build or Improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractors Lib
came Law does not apply to an owner of property who builds or improves themon,and
who contracts for such projems with aconunctorts)licensed pursuant an the Consumers '
License Law.
❑I sur exempt under Sec. ,B&P C for this reason
137M
or Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ane of the following declarations:
have and will maintain a Cenificam of Consent self-mon,for Workers Compcm
n,m provided for by Section 3]00 of He Labor Cade,for the Performance of the
k for which this permit is issued.
have and will maintain Worers Compensation Insurance,m required by Section
ofNC Labor Code,far He pai........f the work for which this Permit is Issu d.
W. s ICI�o enseti/o�n mar.carerand Policy number am:
ier rtt {� 1_-IBJ1V6 C, Polity No.:�i ��tJ�i�O flu
CERTIFI—GATE
OFEXEMPTION MOM WORKERS.,
COMPENSATION INSURANCE
(This section nand not becompleted if the permitis fmonc hundred dollam($100)
or less.)
I certify that in the performance of the work for which this permit is issued,l shall not
employ any Person in any mannerse m to become subject to the Workers''Compensatlort
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cortilicam of Exemption,you should
become subject to the Worker'Compensation provisions of me Labor Code,you must
,J Z forthwith comply with such provisions or his Permit shall he deemed revakcd.
„zy O CONSTRUCTION LENDING AGENCY
[r I hereby offom that there is a construction lending agency for the performance of
ai ti the work for which this permit is issued(Sec.3097.Civ,C.)
Q Lender's N.
Z Lender's Address
U C I certify that 1 have read this application and seem Hat he above information is
lg,H comet 1 agree to comply with all city and county eminences and state laws miming to
O V building construction,and hereby amhorrze representatives of this city to curer upon he
r W shove-me lodgement.c ret for inspection Which s.
May
(We)agree to save,indemnify and keep bermless He City of Cupertino against
v in
of
tsang expenses Which may in anyway acemc ageinslseiO Cily
Z in conacqucncc of the granting of his permit.
ti APPLICANT,UNOERSTANKAND WILL COMPLY WITH AL NON-POINT Issued by: ate
)/z
SOURCE RECULkTIONS, J
Re-roofs
S Signmurcof ApplicanVC mmcror Dam /
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will he applicant or future building occupant sere or handle hazardous materiel
an defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Cod.,Schon 25532(a)1 All roofs shall be inspected prior to an roofing material being❑Ye. :�Na P P � Y g g installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants m dc5ned by he Bay Area Air Quality Management all new materials for inspection.
istrictP ,�''
❑Yes kN.
1 have read thc hamdous materials mquimments under Chapter 6.95 cf he Califar-
niaHealth&SafatyCodc,Scaons255(15,25533.d25534.1undcrsund Hatifthc building
does not currently have eldnam,that it is my responsibility to nodly the occupant of the
r resents whidh must,a metpriormissuanecora Cenifcamof Oc uperay,
7 . Signature of Applicant Date
w raraulfiori>e agent Dai All roof coverings to be Class"B"or better
0
CITY OF CUPERTINO
I� 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 3
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 34240024 . 00
DATE ISSUED. . . . . . . : 07/28/2004
RECEIPT #. . . . . . . . . : 26477
REFERENCE ID # • . . : 04070179
SITE ADDRESS . . . . . : 22954 LONG DOWN RD
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER BARBARA MARTIN
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2652
RECEIVED FROM . . . . : THE BATH ROOM, INC
CONTRACTOR . . . . . . . : LIC # 22324
COMPANY THE BATH ROOM INC
ADDRESS 1910 W EL CAMINO REAL
CITY/STATE/ZIP . . . : MT VIEW, CA 94040
TELEPHONE : (650) 968-7666
E ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 4 , 500 . 00 115 . 56 0 . 00 115 . 56 0 . 00
BPFIXTURE UNITS 3 . 00 27 . 00 0 . 00 27 . 00 0 . 00
BPLANCHK PERMIT FEE 115 . 56 154 . 21 0 . 00 154 .21 0 . 00
BPSEWER SEWER SYSTEM 1 . 00 21 . 58 0 . 00 21 . 58 0 . 00
BPVENT UNITS - 1 . 00 10 . 79 0 . 00 10 . 79 0 . 00
BPWATER UNIT 1 . 00 9 . 00 0 . 00 9 . 00 0 . 00
BENERGY PERMIT FEE 115 . 56 55 . 47 0 . 00 55 .47 0 . 00
BREMPOWER POWER UNITS 1 . 00 47 . 96 0 . 00 47 . 96 0 . 00
PPF,RMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
BREMRECEPT NO. OUTLETS 1 . 00 1 . 20 0 . 00 1 . 20 0 . 00
BREMVENFAN NO UNITS 1 . 00 45 . 39 0 . 00 45 . 39 0 . 00
BREMVENSYS NO UNITS 1 . 00 10 . 26 0 . 00 10 . 26 0 . 00
BSEISMICRE VALUATION 4 , 500 . 00 0 . 50 0 . 00 0 . 50 0 . 00
EPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
MPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 614 . 03 0 . 00 614 . 03 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
-- - -------------- ------------ ------------------
CHECK 614 . 03 18591
TOTAL RECEIPT 614 . 03
WITY OF CUPERTINOo
CU lifflo NO PERMIT APPLICATION FORM `D 7 0qWP7
N# Z, l DateI/ 28
. '10
Building Address: `� Mailing Address (if different from building address):
55Lon do�,� ��d
Owner's Name: Phone#:
PVAY- a rte-- M a v--Vi y0T - 2S'7 - S-3)4.
C ntractor License#:
`�6�e. C3 oovvx �, o
Cont t: Phone& 0-9 -7 Cupertino Bus''p ess License#:
Zi 2 Oae- Fax: l7(0
Building Permit Info:
Bld ❑ XlecPlumber Me
c
Job Description: rL
Residential Ela
Sq.Ft. Floor Area: $/Sq.F .:
Cost of Project: > Occupancy Group:
Type of Construction: Please check this bo ect is a
second-story addition:
o'ect Size: Standard ❑ Laze ❑ 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 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
zb 1�7 7
1 of 3
_. } WITY OF CUPERTINCO
CUPC OFINO PERMIT APPLICATION FORM
QuantityFee 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
BOVERTUVIE 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
BPINTERCEP hid 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 Stomi/Rain Water PLUMBING
BPTR.AP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfin MECHANICAL
BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
_ BREMFURNOV Relo Furnace > l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BRBN NRAPP 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
BREMRESAPP Remodel Res Appliance ELECTRICAL
2 of 3
�� ° *ITY OF CUPERTINOO
CUPE(�TINO PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Group
BREMSIGNAD Rmdl Sips 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 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
MPERNIITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee s foot PLUMBING
ZADDCHG Address Chane BUILDING
3 of 3
aPm >
omem
�a"co 93
6
- Job site:
4 Martin
° „ 72954 Lonadown Rd.
Cupertino,CA 95014
� �(� 408-2573314
Work performed:
The Bath Room,Ific.
Mtn.Viaw,CA 94040 `.
650.968.7688
Lt JUL
Qa CUPERTINO
o.�gm° 101r 7 )r-PFi9'ltll!dl'E1\1Q
Scope of work:
Install new shower pan
= a Install new pressure balanced valve
a S Install new cultured walls d PP6�QV ED
Install new shower doorRempere}g ass
Toilet is exist ng�'ACCr1RDANC` �I I H TH CITY OF
CUPER I v D R ES
a
DATE
SIGNED
This s s ns MUST be
kept on the at all times and a is unlawful
3 to make any changes Or alterations on same
30 33 without written permission from the Building
Department,City of Cupertino.
The stamping of this plan and specifications
SHALL NOT be held t0 permit or to be an
in approval of the violation of any PfOvWpns 01
go1 - any City Ordinance or State Law.
I