03040126 (2) CITY OF CUPERTINO
BUILDING DIVISION PERTR�; ,TaR�INF �.tIVI -
RVkgIN8YDR4sfILFORD DR THE BATH ROOM INC PERMIT NO.03040126
Ouge]kNPI�LZ JACK L AND JANET A 1910 W EL CAMINO REAL ErsMIT�DbD4'r28/2003
(650) 968-7666 SANITARY NO. CONTROL NO.
BUIIDINO PERMIT INFO
ARCH DIC(ENGINEER:
BIRO EIEC' PLUMB MECH
p LICENSED CONTRACTORS DECLARATION
1 hemby affirm the'1 see Ilwnsd under pee ons of Ch pacer 9(commencing Job Description
wlNSectlon7 )or Divitlon3of the Budnoss 'rofesdons Coda.and mylkense i, ����®
nmurmm.an Bea a 22 BATHRM REMODEL ��
Llcen Lk.k
Dau 7VEcuntracm
S
lusd rtend mypicudWlheuadupubticrecnd, JUN 0'3 202
Licensed Profctsknd
OWNE. ecoDER DECLARATION BU'�NG
1 hereby.CS. Nu I am esnmpl from the fiamnnmors e:License c I.A.for the my
o
which
re reu^n.(Salon 7031.5.Business ma Pmfea ell Cade:Any city s musty
which requtra•permit rOn equires
dor,improv,de ecell t fi mash any wrucore v �(�
S^ pa"usItits uum Percent
t to the theappnan fmsoch ant's file.I.. sukmem S Ft.Floor Area �4q5 V on
< (thathe comm.cing wit punuad w1lM provisionslona theComment'sLicenselaw(chapter odo)or Q• Y
(commencing Section 70nd the
basis rof th the Business andon.Any vlosdo)m
(hatSm he r exempt my applicant
and or bur it the subjects
the exemption.Any lineation of �1.�
ca Won]than by any red doll for'permit wbjecu Iha applicant to•civil penally of 3�1 l�qrlY'dr 0 0 Occupancy Type
rot mom than five hundred dollars(f5(10).
❑I,uawn"of Nepmpmy,amy pnployea with wgauthetr wk mmpewtim,
wdnamlha.rorL ana thest^Imomrlwti^lelww«arcemd rarakfsec.lou.awllw Inspections
and Professions Cade:The CannwM1 l^ Urenw law Encs not apply he N Owner or 10 2 — PIERS
ptopeny,w ho bui Ids m i mptowa thermos,aa ou
nd who doch work himself or Nmu fb hla
..employ=,pmvlded thatsuch lmpm,emenu WallU mulled orortenal for ale.If. 103 — UFER
howen,the building or improwmen is sold wiNm ane year of compbon,the owner-
bulkier win hew the bollen of peeving tin he did rot build or Improve for purpose of 104 — REBAR
ale.), 105 - ANCHOR BOLTS
0 1,As own"or the property.am excludwly wnbactes with licensed eontneMM to
wnuuct tin project(See.70".Business And Professions Cade:)The Conlrwim's U- '106 - SEWER & WATER
rotes,Law does not poly man oweer or property who builm nrimllmns themen•A^d. 202 - UNDERFLOOR PLUMBING
-
who wnlraeu for such pmjecu with a Cortise u(s)licensed pmsum he the Conlruwrs
License Law. 203 - UNDERFLOOR MECHANICAL
0 l am exempt under See .B Ae P C fm Nis recon 204 - UNDERFLOOR FRAME
owlcr Dau 205 - UNDERFLOOR INSULATION
WORKERS COMPENSATION DECLARATION
I hereby affirm under penslty of perjury^ns of the following deelanllone 301 - ROUGH PLUMBING
Its, and maintain will minn a Cenbcswof Column he sekf-Insure forWmkerl Compery 302 - TUB & OR SHOWER'
.W.,M prm4dd for by source 3700 of the labor code,for the performance of ft303 — ROUGH MECHANICAL
work for which lhrpermit isbuee 304 — ROUGH ELECTRICAL
0 I new and win maintain Wmaus ComlxnsNon Insurance,As required by Section
3700 d the Labor Cod,_for the perfmmarce of the w"k for which Nr permit Is lamed 305 — FRAME
My Workers Compewtio c see ad"and Poheyrombu Am: 306 - HOLDOWNS
Caden�_Ponry Na: -R t 307 - INSULATION
CER FIGTE OF EXEMPTION FRO KERS'
COMPENSATION INSUIDMI E 308 — SHEETROCK
(Thio"den rued not Mcomplued lithe knoll is forms.hundma dollars(flIXn 309 - EXTERIOR LATH
or lest`) 310 - INTERIOR LATH
I cedfy ,sl In Ne performance of the we&fm which Nr Permit Is issued,I shall nm
employ any person In my manner an As to become subject ee the wmken'Compewrm 311 — SCRATCH COAT
Laws of Callfmnla Dam 313 - ROOF NAIL
Appliant
NOTICE TO APPLICANT:IL iflm making this Cuffiate of Exemption.you should 501 — FINAL ELECTRICAL ENERGY
bumme subject to the Worker's Compensation pmvidon,of the labor Cone.you mud
Z forthwith comply with such pmvednnsorthis puellmdlbedecmedrewdua 502 - FINAL PLUMBING ENERGY
CONSTRUCTION LENDING AGENCY
503 - FINAL MECHANICAL ENERGY
I hereby NUM Net Nem 129 construction lending agency for One performance or 504 - FINAL BUILDING ENERGY
the work for which this Penn lAblamed(Sac.In",Ch.c.) 505 - FINAL ELECTRICAL
C Lammers Name .
z LemaersAdd•ess 506 - GAS TEST
1 certify that 1 haw read this appliance and sum that the'W"Inrom,Nw Is 507 — FINAL PLUMBING
.cL 1 at=to comply with all city and county ordinances Ad sou laws re1Nng M
rV^ Wilding Continuum.And hereby AuthOlins Of this City 10 on="pro fice FIN MEC CAL
If7 shove-men i..d prop.uy,for Impecdon purposes.
fy (we)as.N aro,InacmNy and keep harmless the City of Cupertino against 0 9 F I
,y liabilities,judgments,cau and expenses which may In any way a"rueAgainst aidCity 5 NG
In consequence of Ne granting of this perm 1. Date
APPLICANT U ERSTA Df AND WILL COMPLY WITH LL 1 ON-POINT Issued by:5 C WORKS
SOURCE REO.) TIONS i
y � �8 D� Re-roofs
signwnm eek Contra or of Roof
A3:ARDOUS MATERIALS DISCLOSURE Type .
MI)the Applicant m four,Wilding oxupantdom"Ndk umaterW
Ad dennd by du Cupertino Municipal Code.ChaNer 9.13,and the Hutth and Safety
Code,Section 25533(.)1 All roofs shall be inspected prior to any roofing material being installed.
Oyu use equipment or device
OI e
Wil the applicant m future building{occupant devices which
If a roof is installed without first obtaining an inspection,I agree to remove
Int headou,dr cenNmman,As&find by the Bay Ana Air Quality Management all new materials for i ection.
District?
OYa (p1e1a .
Iban mdthe h'adwsmdeddsmgaimmcwunder Carrier 6.95orNeC,Rrm-
.L 3H sl h @Sd"yCode,Swd=Y55o5.33533 sed i553a.Imdemwm thdlf es,building '(/
dm,not clown, haw a lananl haw It r my responsihkllly o turfy the Quepanl of the
mgmmmnnts hmnsta tpdnr mrsCcrtirusmor Sign ureof plic Dae
own"a mhos; e.eel Dau�� All roof coverings to be Class "B"or better
-- RTY OF CUPERTINO
CIT'ypF O �
. CUPEI�TINO PERMIT APPLICATION FORM �i
0 3 ° �{
APN # � d Date:
� r
Building Address: Z�3�
J 1 V►� I A- pn .
Owner's Name: Phone #:
v. a- rn, s. �3i No�Z 406-151 -in',
Contractor: (N C License #: / oq j 7;7—
Contact: 13 Ar\j CupF/
ertino Business License#:
Build Permit Info:
Id Elect [? Plumb jKj_ Mech .®
Job Desc tion:
Resid ial 0 �� m ci ❑
ft. Floor Area: o-� X11 $/Sq.Ft.:
t"f
Cost of Pr oje Occupancy G up:
i
Type of istr
Quktity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100Kto500KBtu MECHANICAL
BBOILER3 Boiler> 500K to IM 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 Ener Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
� Z ( 7 � �'
1 of 3 _
E� CITY OF CUPERTINO
CIT
CUPTYOF PERMIT APPLICATION FORM
QuantityFee 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 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 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 rinkler/Backflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BP NT Alt of Drain &Vent PLUMBING
BPWATER InstalUAlter 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 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
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
2of3
CITY OF CUPERTIA
CITY OF PERMIT APPLICATION FORM
CUPERTINO
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
•
3 of 3
fig
66 Job Site:
. " Mr.&Mrs.Birk r
213911 rO dDr,
cupe�ii e, ars56`aVED
IN4o QK'4ngt WITH T14E CITY on
P^fj QUPFRTINO
DINANCE9
3L 36 DATE
0 ThisSIGset
This set of ,ans and specifications MusT
Oe kept on the job at all times and itis un
lawful to make any changes or alterations
the
same o Without
d e°rfor e�gBy: Permission from
the 6'fne'Sai Noolririn6f Cupertino.
The St'iii6WPEi Cerf'ino Rade speCifiCati0R9
3HALL Qt I&a4,CA.94 jrmlt or to be an
ExNAvsT �tarJ IPPra1A650-9%7, e6ti®n of any PraV13,019
M any Lice nsa�#
WITH u
SYHte l8gle
132 ' F(.VOt2E5GE2')T 132
LI(AHT
f
, l
e Scope of work:
a I , 1.Replace shower pan and walls
2.Replace shower valve
. • 3.Install shower enclosure
'� . I❑( 4.Replace vanity,top,faucet
S.Install
6.Replapla Replace
exhaust fan
t� 7.Reinstall toilet
II
1 '
Notes:
1.Shower pan and walla,cultured
t ill,, 2.Shower valve Is pressure balanced
PR283.OFCI at vanity
Shower enclosure ie safety glace
S�puor cent light exhaust fan combo
tFi Itch is to euorescertt light
6 o is 1.6 OPF
3
T T44
1)
nc
All dlmensloro 8 Wee designations This la an odBlnal design entl must BIRKHOL2 Scale:112'=1' Design: 04=10
C given aro subject to vedficaWn on not bs roleaasd or cooled unless
Dara : 04/23/103
job site and adjustment to Bt job applicable fee has been peld or job
condItlone. order placed. Designer
CITY OF CUPERTINO "S.wxM� ,i.td ,i%+"z". °"` "p ♦ .�r ar x'
BUILDING DIVISION PERMIT C� �` Tl/R���1�Mt#.TIy
=,gid
BuZLlpNyBgDRgBgILFORD DR THE BATH ROOM INC PERMITNO.030040126
0 FMOLZ JACK L AND JANET A 1910 W EL CAMINO REAL �IT`SS'8Try28/2003
P (650) 968-7666 SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
ARCNf1EC(ENGINEER:
BLDG ELECT PLUMB MECH
0 0 0 0
�orpo LICENSED CONTRACTOR'S DECLARATION Job Descriptio
iy I bureby efrom that I am licensed under pro along or Chapter 9(commencing
with SCoOon7 )of Divlslon3ofd¢Bueinesae rofculons Code,and my license ie 1V
a Ott r
Z �n cfmrcean frau » (y. <f'y2. BATHRM REMODEL
Da¢at Canlncwr 9
st d ARCHrIECrS DEC ATION JUN O 3 20033
1 undersand my plane Mall he used n public rueords
3 u. Licensed Prior cnbnal - �U1L®���
3D
OWNER-BUILDER DECLARATION
1 he eby affirm M
that I nm exempt room ,Contractor's License Law for the
0 0 following rcuon.(Section 70313,Business and Rofeuiung Code:Any city or County
29 which requires a permit to COWMWL arm.improve,demolish.or repair any slru<lure
Fel^ prim m iB)uuance.aIgo requires the applicant for such permit to Rte A signed statement
rig < thathelslicensedpurauant to tho pmvisiongnfdM Contractors License law(Chapter9 Sq.Ft.Floor Area $y0 fti n
i � (commencing with Section 70W)of Divinlon 3 Alto,BuSlnestand Profcuinna Cndc)Ar M
Mal he Is exempt MCMUnM and she buts for the alleged exemption.Any violallon A(
Semon 7031.5 by arty applicant for a permit subjects Me applicant 10 A civil penglty of 3AIN NQEftT 00 Occupancy Type
not more than fn hundred dollen($500).
❑1,As Owna of the property.m my employed with wages u their tole compew0on, ,7,r'
will do the work and MM
the It Ant lnmed 14
ma«ered for We(Sec.7° ,eusimu — OUND?RT+fiW Inspections
And pmfetMo A Cade:The Contractor',License Law don not apply to an owner of 10 2 - PIERS
property w ho builds or Improv,,thereon,and who does Such work him set f Ar thmugh his
own employees,provided Matsuch lmpowments arc not Intended moRemd for sale If. 103 — UFER
however,the building or Improvement 1,Sold within one you Of completion,the Manor-
Wilde,will have the burden of proving that he did not bund AT iMpfow for Purpose Or 104 — REBAR
ASIA.). 105 - ANCHOR BOLTS
❑1,as owner of the propeny,am exclusively contracting with Licutsed contractors to
construct the pmject(Sec.70",Business and Predations Ced,:)The Contractors U. 106 — SEWER & WATER
Come Law does not apply m an Am of property who builds or Improves thereon,And 202 — UNDERFLOOR PLUMBING
who contracts for such projects with a contractor(s)licensed pursuant to the Conuanmrs
License Law, 203 - UNDERFLOOR MECHANICAL
❑I xm eaempl under Sec .B A P C f."hi.Munn 204 - UNDERFLOOR FRAME
°r °
WORKER'S COMPENSATION DFiCLA0.ATateIO 205 - UNDERFLOOR INSULATION
I hereby alllmt under penalty of perjury one of the following declarations: 301 — ROUGH PLUMBING
❑Thaw and win malnWna CeArum OfConsenuo sel6ingurt for WorkehCompon• 302 — TUB & OR SHOWER
cation,As pmvldcd for by Section 3700 of the labor Code,for the performance of dm 303 - ROUGH MECHANICAL
Aorta for which this pmmltlaimeed. 304 - ROUGH ELECTRICAL
❑I have and will maintain Sooners Compensation lognomce,As required by Section
3700 of We Labor cora far M,performance or arc work for whim this permit is tutted. 305 — FRAME
My Worker's CAmpensaliot late lreAce eemmr and Policy number am: 306 — HOLDOWNS
Carder. Policy NA.-J, )3.J1 307 - INSULATION
CERTIFICATE OFMEMPIUN FROM yrO KERS
COMPENSATION INSU101NCCE 308 - SHEETROCK
(Missectlon need not Wcomplemdlflhe permit is furon,hundreddollm(SIM) 309 — EXTERIOR LATH
m teas.)
I certify that in the performance of the work for which this permit is issued,I shall not 310 INTERIOR LATH
employ any person In any mannerw AS in become subject to the WArken''Compensation 311 — SCRATCH COAT
laws O(Califomla.Dere'
Appliunl 313 - ROOF NAIL
NOTICE TO APPLICANT:If.after making this Certificate of Exemption.you Mould 501 - FINAL ELECTRICAL ENERGY
become Subject to Me workers compensation pmvtuons of Me labor Code,you most
.,'Z fore.ilhcomply with such pmvt,)onsn,this purnitMail Wdcemedmvoked. 502 — FINAL PLUMBING ENERGY
zo CONSTRUCTION LENDING AOENCY 503 - FINAL MECHANICAL ENERGY
[-t
I hereby Affirm that there is.construction lending a;cncy for the Performance or 504 — FINAL BUILDING ENERGY
a> the work for which this permit is iumd(Sm.3097.Mr.Cd
W q Leader,Name 505 - FINAL ELECTRICAL
= z Lend,raAdd., 506 - GAS TEST
U OI unify that 1 haw Toed Mis application and sou Mat the above information Is507 - FINAL PLUMBING
Iy coned.1 agree to comply with all city and county ordinances and state laws relating to
O SH building construction,and hereby suthorior represenlaliwt of this city to cmm upon the FIN MEC CAL
w Move-mentioned prop any for inspection purpoaes.
(Wc)grime to sew,indemnify and keep hsrreleu(he City of Cupertino against 09 F I
fn IIMIIinu,judgmenW costs and expenses which may in anyway ans7oe against told City 5 NG
U in consequence of the rimming of this permil.
�••� APPLICANT U ERSTA)DS AND WILL COMPLY WITH LL ON-POINT Issued by:5 C WORKS Date
SOURCE REGU TIONS
u� Re-roofs
Signature qtl aComm.tm
AZARDOUS MATERIALS DISCLOSURE Type of Roof
WIIl dm applicvntm(calmOccupant
,bullJingtoM or handle rardousk mamdal
AS defined by the Cupertino Municipal Code.Chapter 9.11,and Me Health and Safety '
ode.Section 23531(e)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes O NA
Will the applicant Or fOm'we building Occupant use equipment or device,which If a roof is installed without first obtaining an inspection,I agree to remove
emit haurdnus air contaminants AS corned by the Bay Arta Air Quality Management all new materials for i ectlon.
District?
Oyu ON.
I haw mad the hxurdtmt materials requirements under Chapter 6.95 of the Califnr. '/X
nix Health A Safety COM.Secdons 15505,15533 and 15534.1 understand thin if the Wilding
dura not currensl haw a mnanL that h h my mepongihlllty m notify Soon aaupanl of Mc
Mquimmcnu hmuubu et pdar nuance Ada CertiOcem of cupan $ig0 ser4ofp1i C Da e
X01 All roof coverings to be Class"B"or better
Owner o mhodr d agem Dam