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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
CONTRACTOR INFORMATION:
BUILDING ADDRESS:
BATHROOMS
BY REMODELING SP
�-RMITNO.
1491 PRIMROSE WY
0,1010191
IER'S NAME:
1422 SARATOGA AVE
APPLICATION SUB DATE
FLORENCE SHENOY
01/29/2003
PHONE:
(408)328-6700
SANITARY NO. CONTROL NO.
ARCHITTCI'IENGINEER:
BUILDING PERMIT INPO
BLDG ELECT PLUMB MECH
LICENSED CONI RACTOR:S DECLARATION
9
Job Description
1 hereby affirm Ibar 1 am IiceneJpppppp�der provisions Irl Chapter (commencing
with Sec X))of Division 3Of1.a;j nexsandPo1 ions Cta1c,and my license
in full Ra J cc r
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REPLACE BATH FIXTURE TILI
'NALEp
Licmasc lura ....
Dal[ C iRlabd B,M`3
AR IIITIeCT$ C1.ARAT�ON
I understandmy planssholl heused aspublic records
FEB 2 12003
Licensed Pn lcxsi... I
OWNER BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
BUILDING
reason. (Section 7031.5, Business and PmfaYsiuns Code: Any city ur County
which re9uires a panni( to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit m file a signed statement
that he is licensed pursuant In the provisions Of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
,s..rw
$13Y40tion
(cmnmencing with Section 7010) OF Divi.ian 3 of the Busi nese and Pndemmus Cute) or
that w is exempt therefrom and Ne basis for the alleged cscmpunn. Any violation of
3e
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a Civil penalty of
not more than Five hundred doll.. (S500).
1, as owner of Be, property, or my employees with wages as their sole compensation,
—
equtred Inspections
will do Fire work. and line someone, is nut intended or offered for sale(See70x4, Business
and Profession.. Code: The Committees License law coo nut apply to an Owner of
102
— PIERS
property who builds or improves thereon. and who doessuch work nimselfbr through his
bon employees provided that such improvements am not intended or offered for sale. If,
103
— UFER
however. Ne building or improvement is stud within one year of completion, the mvner-
104
— REBAR
builder will have the burden of proving that he did not wild or improve for purpose of
sa1e.).
105
— ANCHOR BOLTS
I, as owner of the property, am exclusively contracting with licensed convenors to
106
— SEWER & WATER
construct the project (Sec toad. Business and Rofession t Code:) The Conlracmr's Li-
ectem Lawdoes not apply toanowner of property who wildsorimproves the¢on.and
202
— UNDERFLOOR PLUMBING
who contracts for such projects with a cnntranurtx) licensed pursuant to the Cnmracwr'e
203
— UNDERFLOOR MECHANICAL
License Law.
❑ I am exempt under Sec. .B&P C for this Maon
204
— UNDERFLOOR FRAME
Dal
205
— UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION
301
— ROUGH PLUMBING
I Family affirm under penalty of penury one of the following declarations:
302
— TUB & OR SHOWER
El [haw and will maintain a Certificate a ofConsenttoseBLnsumfor Worker's Compel
cation, provided for by Section 37(X) of Ne labor Cute, for Ne perlormancc Of the
303
— ROUGH MECHANICAL
work for which his Permit is issued.
304
— ROUGH ELECTRICAL
1 have and will maintain Worker's Cnmpcn t and Insu.nce, as required by Section
3 0 5
— FRAME
391X1 of NC Luton Code, for the pt'rfermanw the work far which this permit is issued.
M Worker's Compensation inmranceea' ndPolicynumberam:
306
— HOLDOWNS
nicr: 10YI-1v' PolicyNo.: 00 o0.5
307
308
— INSULATION
SHEETROCK
CERTIPICATF. OF: EKEM Pr10N PROM WORKERS'
COMPENSATION INSURANCE
—
Chis section need of be cmuderMdtic rcrmit is for one hundred dollars ISIh(d
309
— EXTERIOR LATH
or'e's)
310
— INTERIOR LATH
1 cenify that in the performance OF the work for which this permit is issued. 1 shall not
311
— SCRATCH COAT
employ any pe.nn in any manner so as in become subject to the Workcts Compensation
Law. of California. Date
313
501
— ROOF NAIL
-
— FINAL ELECTRICAL ENERGY
Xo
IGTOAPPLICANT:I I. it It,daking his CcnilicateofExemption. You 'be.1J
become subject o the Worker's Compensation provisions of the labor Code. you muss
502
— FINAL PLUMBING ENERGY
forthwith comply with such provisions or this permit shall be deemed revoked.
503
— FINAL MECHANICAL ENERGY
CONSTRUCTION LENDING AGENCY
I hereby affirm Ford then, is a construction lending agency for the perIonourme of
504
— FINAL BUILDING ENERGY
the work for which this permit is imucd(Sec. 3007. Civ. C.)
I.enJet's Name
505
506
507
— FINAL ELECTRICAL
— GAS TEST
— FINAL PLUMBING
LendersAddrea:
I ccnrcy that I have read this application and state that the above information i.
correct. 1 agree to comply with all city and county ordinances and state laws relating to
nodding comFmction. and hereby anmoda representatives of mix city lot enter upon the
5
FINAL MECHANICAL
abovomentioned property for iro,red nn purposes.
O 9
FIN
(We) since to save, indemnify and keep Went the City Of Cupcnino against
City
G
liabilities. juJgmenB,cna and expenses which may in any wayaccmc against mid
5
N f
11
AP nwq NT UNDEA the6 anAND5this
ANDrWILL COMPLY WITII AL}}} N N POINT
Issued bye l
— ' WORKS Date
SOU .E R[GUI. 5.
Re -roofs
Type of Roof
Signa uml,f ApplieaMcommeml Dam
IIAYARDOUS MATERIALS DISCLOSURE
Will Ne applicant or future building omuplum sore or handle Cargill malenal
Icfined by the Cupenino Municipal Code, Chapter 9.12, and the Ilcalth and Safety
. Section 25532(arlAll
roofs shall be inspected prior to any roofing material being installed.
[:)Yes ANo
If a roof is installed
without first obtaining an inspection, 1 agree to remove
Will the applicant or future building occupant use equipment or devices which
unit hazardous air conmmina is n%dcf'IrM by the Bay Arca Air coolly Management
all new materials
for inspection.
Disoia/
❑ yes Nc
1 have read the humrdnus nlamfials mquiremenLs rmtkr CFnpmr 6.95,,(tine Calif om-
ma Hcallb & Safety Ci k. ScNn® 25515.25533od2553Y 1 un@rslunJ Nat if plc wilding
ot aunendy have ¢Iran, Nat u is my responsibility to nMfy the rccupam of the
does a.'.
r,gpirentylat,wmrn melpdortoi„Oanaora�eni camorpanex
Signature of Applicant
Date
Y/
All roof coverings to be Class "B” or better
Irmm mwrimdagem Date