03010191CITY OF CUPERTINO
1 ,"r»"�. x 111,11�
BUILDING DIVISIONPERMIT
CONTRACTOR INI?OIR :
u ILDING ADDRESS:
BATHROOMS BY REMODELING SP
`ERMITNO.
1491 PRIMROSE WY
03010193
OWNER'S NAME:
1422 SARATOGA AVE
APPLICATION SUB DATE
FLORENCE SHENOY
01/29/2003
ONE:
(408)328-6700
SANITARY NO. CONTROL NO.
ARCHITECDENGINEER:
BUILDING PERMIT INFO
RLDG ELECT PLUMB MECH
0 0 0 0
00
w.
LICENSED CONTRACT'OR'S DECLARATION
1 hereby affirm Net 1 am licensed oder provisions of Ch t Y ammencin
with Sec )nf Divisionm licensedp aper (commercial,
n Nth ncss and Profcssiof Code. a9(com license is
O CSCfIpIIOD
LIZ
lot ra d e G' o
Liccme Imo c.M
DateCt r
AR t11TEC'IS
REPLACE BATH FURE/TILING
7
LARATON
I understand my plans shall be used as records
W U
public
Licensed Pm(essmnal
OWNER -BUILDER DECLARATION
C)�
00
I hereby affirm that 1 exempt from the Contractor's taw for Inc
Any
00
$
reaso 1. : c
Code: Any city or caunry
which nqusm a permit
whop following es a blood to BL.0. t, aide. and Prow. de a demolish,
construct, alter, improv, demolish,
repair any structurepriortmeat
i y
Fo
re fi
that he its licensedpre inion o forsuch pewit lLiense L w (Cha mem
een ed pursuant
ur so uant to the
Sq. Ft. Floor Area $13YaD181[ion
��.
(cometecingwiJpSectiou0theproviviomofthcCanuandcnulsw(Chepmr9
(commencing with Section700KEand of Division 3 of, Business atl Professions Cade) of
that is taertfrom and the basis for the
..
a
alleged exemption. Any violation of
eaxe
io 31.5 b any applicant for a permit subjects the applicant toacivil penalty of
.arisen than Eve
not more Nen five hundred dollen ($500).
C
Occupancy Type
❑ I. u owner of the property, or my employees with wages u their sok compensation.
will do the work, and the structure is not intended oraffered foraal,(St .]044, Business
and Profcuions Code: The Convector' License Law does not apply to an owner ofequired
—
102 - PIERS Inspections
Property who Goulds or improve thareon. and whodoes such woh hrriefor through his
own employers, provided that such improvements art not intended or offered parents. If.
103 — UFER
however. the building or improvement is Wild within one year of completion, the owner.
builder will have the burden of proving that W did not Wild of improv for purpose of
104 - REBAR
01.
105 - ANCHOR BOLTS
the Property, 7 .Bam einessadvely contacting Coe:)Thsedcancuor'. i-
❑beet as the Project
construct the projen (gee. ]044. Business and Professions Cotler) The Conuumri Li-
106 - SEWER & WATER
camelawdoesnotapplytoanownerofpropenywhobuilesorimprovesthe¢on.and
202 - UNDERFLOOR PLUMBING
o contracts for such projects with a conmcror(s) licensed pursuant to the Contractors
eau Law.
203 — UNDERFLOOR MECHANICAL
Iam exempt under sec. ,B&P C for N;e reason
204 - UNDERFLOOR FRAME
OwnerDam
WORKER'S COMPENSATION DECLARATION
205 - UNDERFLOOR INSULATION
1 hereby a1Erm under Penury of perjury one of the following declarations:
301 - ROUGH PLUMBING
I have and will maintain •emitiems of onsenuo self-imum for Work,,', Compaq.
302 — TUB & OR SHOWER
seetion, as provided for by Section 3700 of the labor code, for the perfawmtce of the
303 - ROUGH MECHANICAL
work for whichillapewitk issued.
304 - ROUGH ELECTRICAL
❑ I have and will maintain Worker's Comi en anon Insurance. a required by Section
3]OUafthe Code,
3 0 5 - FRAME
Labor ftetheperfortam. a work far which this permit is issued.
M Wohcr'sCompensationlnsuranceea dPolirynumneran:
306 — HOLDOWNS
mer:✓6TAT� to PohcyNa.: Of<6 OOSOJt
307 - INSULATION
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
308 - SHEETROCK
Mi. section need not be completed if the pew it is form. hundred dollars (S IW)
309 - EXTERIOR LATH
Ickss.>
310 - INTERIOR LATH
Nat in the performance of the work for which this pewitrkeW Com shall not
employ
employ any person in any Manor an az m become subject to the Workers Compensation
311 - SCRATCH COAT
Laws afC.Iift ia.Data
313 - ,ROOF NAIL
501 - FINAL ELECTRICAL ENERGY '
'Applicant
NOTICE TO APPLICANT If. after making this Cenifcate of Exemption, you should
become subject to the Workers Compensation provisions of the Lehr Code, you must
forthwith enmplywith such prodskaaarthis permm
itshallhedeeedrevuked.
502 — FINAL PLUMBING ENERGY
OZ
CONSTRUCTION LENDING AGENCY
503 - FINAL MECHANICAL ENERGY
I hereby alRw that there is a construction lending agency for the performance or
504 - FINAL BUILDING ENERGY
the
Qthe work work Name fill which this pewit is issued (sec. 3097, Civ. CJ
505 - FINAL ELECTRICAL
z Iander'sAddnas
506 - GAS TEST
Q 1 cenify that 1 have read this application and sure that the above information is
Fcorrect l agree to comply with all city and county ordinances and sum laws rotating to
507 - FINAL PLUMBING
t.7 buildingconswction,andherebyauthorimmprescnutivesofthiscitytocrumuponthe
5 ri.0FINAL MECHANICAL
U] above-mentioned Property for inspection purposes.
indemnify
O9 FIN
e to , and keep harmless the City of Cupcnino against
0. (We) agreave
In Iiabilides,judgments, costs and expenses which may in any way decide against aid City
5 NG
z in comcq ence of the granting of this permit.
AP NT UNDE ANDS AND WILL COMPLY WITH AL N -POINT
f
Issued by51 - WORKS Date
SOU EREGUL s.
Re -roofs
Type of Roof
igadmdm (AppbnnUConuutor Dam
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle 1mrso ous material
u defncd by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Cade, Section 25532(x)? `/
❑Yea 3�No
All roofs shall be inspected prior to any roofing material being 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
emit hazardous air conanine ts a defncd by the Bay Ana Air Quality Management
all new materials for inspection.
Distri ?
0Yes No
1 have read the hasaNtms materials mquinmcnts under Chapter 6.95 of th,Califor-
niaHealth& Safety Code. Stct in.25!u)S25533 and 25534.1 undcnund thou BtW building
dues not cuncmly haw mount, that it is my responsibility m notify the occupant of the
req irem tswmen mmprior m;aaan¢onceN a of .paney.
Signature of Applicant Date
/
neral uthorinJegcm Date
All roof coverings to be Class "B" or better
rs�-
CITY OF
CUPEIZTINO
CITY OF CUPERTINO • 03 0/0 1 ? 3
PERMIT APPLICATION FORM
--Iiiu—antity Fee ID
AP #
Date: 11-g �/0,3
BAPPLOTHER
Building Address:
/f19/
MECHANICAL
Owner's •
�e
/ 1
Phone #: C S�O�J %%� - o2/�•Z
BUILDING
Contra r: _ A
License #:
BUILDING
BCONSTAXB
Con. Tax for BQ Zone
BUILDING
Conta
Phone #:
BUILDING
Applicant/Contractor:
Constax - Resi/Mobile
BUILDING
Building Permit Info:
Elec 600V <= 1000A
Bldg Elect Plumb Mech
BELEC1001
Job Description:
ELECTRICAL
Residential: of oGz -Commercial:
Elec Svcs 600V <= 200A
Sq.Ft. Floor Area:
$/Sq.Ft.:
Energy
Ar chitect/Engineer:
Valuation:
EneEgy Add Multi
BUILDING
BINVESTIGA
Investigation fee
Type of Construction-
Occupancy Group:
Comm. Housing Mit. Fee
--Iiiu—antity Fee ID
Fee Descriptio . n
FeeGroup
BAPPLOTHER
Other Appliances
MECHANICAL
BCONSTAX
Construction Tax
BUILDING
BCONSTAX
Ind/Off/Comm/Quasi
BUILDING
BCONSTAXB
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
EneEgy Add Multi
BUILDING
BINVESTIGA
Investigation fee
BUILDING
BMITIGATC
Comm. Housing Mit. Fee
BUILDING
BMITIGATR
Res. Housing Mit Fee
BUILDING
BMNEWMULTI
New Multi -Family Res
MECHANICAL
BNEWMULTI
New Multi -family Res
ELECTRICAL
BNUCOMME
New Comm Electric
ELECTRICAL
BNUCOMMM
New Comm Mechanical
MECHANICAL
BNUCOMMP
I New Comm Plumb
PLUMBING
tof3
,,%AT aROOMS
by Remodeling Specialists q
2SARATOGA E
TELEPHONE 08) 378-6700CONTRACTORS LIC•#674083 Date
•�,
t-,�� a .a I
I
I j
— SUBMITTAL j
,
• 1 � 1 I I' 1
2003
�- ---� ippb p L.
c r R VED
BY: _ —� INA ,CO DANCE ITHiTHEjCIT4i OFi
C.l1f+ 'TIN I Cqb 1
Rtp
(/ AND' 0 DINANCES
SIGNED r
his set f pl ns i .... i
be kept c t th specifications MOS1
I ,at all times and it un
lawful to nak! onyi-changas; or I
oh same vithc It Written alteration'' I
i . the buildir ; pF It.. CI - Peimis3i9rt.,frarri_. i
The stam r bf Cupertiho.
P go thislplamandlspeciiicaattr
j I i
SHALLop
be field to
Pei old or fu i approval
of the dotatidn "of any p}ryv„t I
{ f
,an
City Drd_ i lance or h
I
I