03060052 (3) CITY OF CUPERTWO ' *,kwe
BUILDING DIVISION PERMIT 9CONT' RACTOR INF,ORMATIO>
BUILDING ADDRESS: PERMIT NO.
THE BATH ROOM INC 03060052
ja&ItA,pTei�f3s PERMIT ISSUE DATE
1910 W EL CAMINO REAL 06/06/2003
SANITARY NO. CONTROL NO.
(650) 968-7666
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG' ELECT PLUMB MUCH
300
LICENSED CONTRAC I)R'SDECLARATION Job Description
UW 1 hereby M.that 1 me It •�_yV" der provisions of CNpecr 9(commencing p
i wiNS.'on )of DivWtm3ofz uw{tesaMPeofesmoc Code.endenylicemmis
+> in full fo -delle ✓
;qz
Lice c„ Contractor Z BATHRM REMODEL FO MALE0
t-p Dam Contrecmr
qq' 7W ARCHf LA ATION
t I un d my pha;,hall k used a public mcoN
)�u JUN 2 5 2003
•G Licensed Pndcssional ,
`g y
OWNER-BUILDERraptfrom
DECLARATION
9�y I hemhy afnrm that I em exempt from the Contranm',Littnm Law for the
zoo following mnson.(Section 703M,Business and Profession Code:Any City OrCounty BUILDING
$ � which require a permit to conswcL elect.improve,demolish,or mpair any structure
prior 0 its issuance.also requires the applicant for such permit to file uigmcd statement
-Zo that kislicensed pursuant toNeprovisio;ofthe ComemmriLimmeLaw(Charter 9 Sq.Ft. Floor Area $SMVtion
lice (commencing with Section 7")of Division 3 of[be Boamensuld Prote.her,Code).1
Net he is exempt therefrom and the basis for the alleged esempeon.Any violation of
Section 7031.5 by my applicant for s permit subjects the applicant to a civil penalty ofp y 7YP
not mom Man In hundred ddiae(SSW). 32#V7lS�ek10 ecu araC e
❑I,as..at of the property,or my employee with wages as thein role eompamathm,
will do the work,and the structure is not intended or offered forside(Six.7W,Business 101 - FOUNDA'> ed Inspections
and Profession,Code:The Contractors Licnre Law docs not apply to an owner of
property who build..improv;dmmun,end who doesmsh work him•elfor through his 102 - PIERS
own employ=,provided Oat Such improvements rte nmimmaded orofrum foreale.if. 103 - UFER
however,Ne building or improvement Is mid within on Sear of completion.Ne owmr-
builder .will haw the wtd.n of proving our he did net wild or Improve for purpose of 104 — REBAR
ate.).
Cl 1.as owner of Me company,amexclusively Conomsing with limused contractors to 105 — ANCHOR BOLTS
construct the project(Sec.7W,Business and prefessions Code:)The Contractor's Li. 106 - SEWER & WATER
comm Law does or pplytoanewmerofproperty who Wild.orImports.Matter.and
. 202 - UNDERFLOOR PLUMBING
who contes, racts for such pmeeu with a conlnctorpm N
)licenced pursuant e Comnctor.
Li< Le"'
1. 203 - UNDERFLOOR MECHANICAL
❑1 am eempt undo this moo
See. .B&P C far this
204 - UNDERFLOOR FRAME
Owner WORKPR'SCOMPENSATION DECLARATION 205 - UNDERFLOOR INSULATION
1 hereby afBon under penalty of perjury mm of the following declensions: 301 - ROUGH PLUMBING
I haw ad will maintain a Certificate efCommnt toselr-inmm for workers Cooper. 302 — TUB & OR SHOWER
137].10)
on,aprovided fo by S;don 37W of the labor Code.for the performance of Ne303 - ROUGH MECHANICAL
t for which Nh permit is issuW.1 haw and will mainam Workers Compensation Insurance.ex required by Section 304 — ROUGH ELECTRICAL
of the laver Cede,for Ne performance of Ne work fee which Nie permit i.Issued. 305 - FRAME
Workers Companies.Instar mrier and mu k,are: 306 - HOLDOWNS
ier'. SAF. I.C- Polity N.,-.7 -V - 6q
ERTIFlCATEOFEXEMpITONpHORKERS' 307 - INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
I.e.)This section need mock completed If permd is for one hundred dollars f1iIM) 309 - EXTERIOR LATH
ro
1 cenify Nit In the performance of the work for which this permit I,issued,I.hall not 310 - INTERIOR LATH
employ any permn in any amber an w to become subject to the Workeri Compensation 311 — SCRATCH COAT
U.of California.Data
Applicant 313 - ROOF NAIL
NOTICE TO APPLICANT'.If.after making this Certificate of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
become subject to the Wotrer's Compensation provisions of the laver Code,you most
OZ forthwith comply with such prnvisioaorthisPermit shall kdecreed myriad. 502 — FINAL PLUMBING ENERGY
zMCONSTRUCTIONLENDINGAGENCY 503 - FINAL MECHANICAL ENERGY
Fr iy+ IwrOy.IRrm Met then i,a emaduellry fo
nn lemdingagenr f performance or _
a> fwork fuwhich this penmituounce(Sec.3097,Civ.C.) 504 FINAL 'BUILDING ENERGY
ILII Undoes Name 505 - FINAL ELECTRICAL
aZ 11
Lender's Add1C506 - GAS TEST
U O L certify the 1 haw revs thi..ppn;tion and,um the the above m(orm.siun ts 507 - FINAL PLUMBING
correct.I•gree to comply with all city and county eminences and haws relating to
OU building construction,no hereby sermon representatives or this city to enter upon ft WFI
MECHAN CAL
ahnve-ro ntiomeA property for iapection prpeaa(We)again to ave,indemnify and keep harmless the City or Cupertino usher 9rn liabilities,judgments.costsand expenses which may In any waymemeagainstmidCity51 G
U 7 In consequence of N gnnling of This permit.
rte• APP ANT UND RSTANDS AND WILL COMPLY WITH L NON-POINT Issued by5 WORKS Date
SOU REGULA S.
Re-roofs
i rt pplm=RDDUS MATERIALS DISCLOSUR sec Type of Roof
Will the applicant or forum wilding ext upmutom or W Mk Woodcuts material
as defined by tk Cupertino Municipal Code.chapter 9.13.and Ne Health and Safety
Code.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
[3 Yes DID No
Will the applicant or fuWm wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I.4dWnws
ir h xaosm,air mnuminar s a defined by ft Bay Am•Air Quality Management all new materials for inspection.
District?,
❑Yea We
1 haw mad the h;Nm
anusateriab requirements under Chapter 6.95 of the Califor.
Hear"Sdety Code,Sections 25505,25533 and 25554,1 understand that Ifthe wilding
not comedy how a tont.Ndm at it is my responsibility to notify occupant of ftuihicaRkmet p inummehccrtiftc for Signature of Applicant Date
cr rim cot Do All roof coverings to be Class nBn or better