06080238 CITY OF-CUPERTINO
, T, 11,
.T
BUILDING DIVISION PERMIT tat
BUILDING ADDRESS: THE BATH ROOM INC 06080238
10345 FARALLONE DR
ER'S NAME: PERMITISSUEDATS
MIYAKAWA 1910 W EL CAMINO REAL 08/29/200(5
MONE: SANITARY NO. CONTROL NO.
(650) 968-7666
ARCHITECT/ENGINEER: BUILDING PERM".INFO
BLDG ELECT PLUMB
joo LICENSED CONTRACTOR'S DECLARATION
I bereth,sNal at I am licessom order provision of Chapter 9 Job Description
with Seethat 70110)of DIAtogta 3 of ft Business and ismitommou,Code,and my Ikon.I.
in fell force bd.fr.L
Y REMODEL 40=efffiN NON STRUCTURAL
LionseClass Le., A67330
Damcmusese, 2!3�d &4'fe"_
—I- -I ARCHITECTS DECLARATION
1 understand my pins shall N used as public records
tsd Licensed Professional OWNER-BUDDER DECLARATION
I hereby affinn that I am exempt from the Commanor's License Lsw;for the FOYA ED
a following memo.(Saction 7031.5,Business and Prefectures Core:Any city.,..my
129 which acquires a paroult he common,altar,Improve,demolish,or unfair any structure $15000
•1;. priorta its isautrunce.alsomquirestim,applicant fimstach Krusilus file asignedstancencut Sq.Ft.Floor Area
that he is licensed pursuant M the provisions of doo C01.1sker's Liccom LAW(CWPtm 9 Valuation
a (cournmencing with Secuon 7000)of Division 3 of me Business and Prollossins Code)or
that he is exempt 11creficill and the bucht for the alleged assumption.Any violad,an of
Section 7031.5 by any applicant per a permit subjects me applicant to a civil penalty of ccpu,,a,,ncy Type
no,mom than five hundred dollars(M), ell
A.their able compmenuumm,
0 1,..ef�prcM,mmy.pl.y..Ub.r h'
forsa
Re aired Ins actions --�
and Profiesmans Code:Twill domewark Codex he Conuoustor's Licssm,Law does not apply as an owner of
property who Wildsorimposecs moment.and whodoassuchwarichimselfor through his
ormemploymes,provided mansuch unproncroorm,so an,handed oraffersed for Bale.If,
homm,me building or Improvement is sold within ance year ofccompleduar.the meres-
bull&'win Mw ft immune of movitri,that M did num Wild or improve for Variants,of
.Is.).
0 1.as owner of she property.am exclusively contracting with Round commuctons to
concruntel use,projea(Seg.70aa,Business and Profession Code:)The Conturcurns U.
comes LAW don not apply as in mancer of properly who WiWs or improw,thembon,and.
who cranuarcut per such projects with a cormwour(s)licensed pursent W ft C(aftracirces
License LAW.
❑I am exempt under Set B&Is C for this ressmor
l a Date
I WORKERS COMPENSATION DECURA71ON
� I bessay Lffirm under penalty of perjury ons of the following decluentalmor
lown d*111 maintain a CIrlIctuo or Consent he self-Inuit for Wormer Comn*
,as provided for by Secure 3'1'00 of flas Labor Code,for the performance of me
o"'for which this Permit is issued.
I I haw unit will maintain wmsbues compensation Insurance,as required by Section
of 0.Labor Code.far the performance of me work,for which this permit I.issued.
MyW., "s rN.so I use carnm.nd Policy amobarture:
Canil. In X;J,2 Policy No.: 13?311-3�e_5
0
CERITIFICAMOF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Dnos motion need sales completed Irma Permit Is return hundred dollars($100)
or less.)
I cerfil)v the,I.use marommors.of the vustic for Which this anal,is Wood.I must am
employ any person in my mourneers,as as become subject in ft Wormoux'Coniscresuflon
Laws ofCsfirmeh..Data
APPIbnL
NOTICE TO APPLICANT.If.after meting this Certificate of Exemption,you should
become iubject to the Worker's Compensation previsions of the Labor Code,you am
Z forthwith Comply With such Provision Or this Permit"I edthernmed revoked.
Z 0
E D! CONSTRUCTION
hereby affirm CONSTRUCTION LENDING AGENCY
this mere is a cotru
nsction lending agency for the performance of
the work for which this permit issued(Sec.3097,Civ.C.)
dUndoes Name
F�
:0 z League.Address
U0 I certify that I haw nod this application and sum this the now informadun is
I,L Correct.I 1juM 10 Comply With all City and county ordinances and state laws relating to
0 building construction,and hereby auchofice mpoexammins or this city to enter upon the
U
r W used propertyfor inspection purposes.
(We)agree to saw.indemnify and cup harroloss me City of Cupertino almost
fiabilitics,judgments,costs and expenses which may In my my acme against said City
Uin consequence of the gronting of this Permit. Date
APPLICANT UNDERSTANDS AND WAA.SOMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULEA'nq.
Re-roofs (�;7
Signatup4l'A,plicarnoCnasclor W,—.--6
df_ HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will done applicants,or Anne truildfing=upset sacce,or handle hansuchno truncrud
as dallmod by 0.Capsorm.Municipal Code.Chapter 9.12.and the Health and Safety
Section 255324)? All roofs shall be inspected prior to any roofing material being installed.
0yes V,5'No
Wilift applicant or future Wilding occupant use equipment ordevics,which If a roof is installed without first obtaining an inspection,I agree to remove
crall.luroardums.1,comeminums as defined by our Say Ana Air Quality Management all new materials for inspection.
District?
0yes 7�1�
I heve mad the hazardous materials requirements under Chapter 6.95 of the Califor.
nia Health&Safety Code,Secoom 25505,25533 and 25534,1 understood that if&building
does on,currently how a inans,that it is my reasonability in WoufY the occuproul of due
requirements wbichm t prior on issuance of a Certificate of`cFoP'9`4G Signature of Applicant Date
O.ud'auffichri — 11Dow 41111 All roof coverings to be Class"B"or better
I /, I —