01090025 CJ BUOF
BUILDING
PERTNO
I PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERNIff Na
20289 STEVENS CREEK BLVD SOUTHBAY CONSTRUCTION CO INCO1090025
OWNER'S NAM1tE: APPLICATION SUB DATE
NOVA CARE 511 DIVISION STREET 09/06/2001
PHONE: SANITARY NO. CONTROL NO.
(408) 379-0400
Fes,O O ARCHITELT/ENGINEER: BUILDING PERMIT INFO
pl- BLDG ELECT PLUMB MECH
8y�
z LICENSED COrvnBACnder p DECLARATION Job Description
1 hereby abom that I am bcen5ed under pruviaions of Chapter 9lcommenemg IJ
'y_� xhn section]tluokarDiviainn3onne Busmeas ane ProressinnxCWe.and yheense TYPE VN, SPRINKLERED, TI . OCCUPANCY B
m y_ ism full force and ertac p
z i .License Cla Lic.X ATO I(J /.�
O Date Co"oul",
3 a y ..a shall
to DECLARATION
1 uasdersland Iny plans shall be used as public rteords
Syr,
aY
i p O Licensed Profosioaml
'K-,rc,, OWNER-BUILDER DECLARATION
W-v 1 =am.Sect o but 1 1. eBusin from the Comms Coe License y Low,fur the
355
M?o following=am.eram,,t ]or, 1. too,s and I...drowns Code:Any city ,«roomy
which it,isssn e..1.oroonamet,alioimprove.h poom1 hepar on,sbunhom
em
a3 'ori«I th I an4 is isi tf hail 's License
(,Sledmmm<m, _. - . ._ _ ._ _. _. ._..._ _...� ___ .............
(bathe medp n7M Pm fthet ,,er rs an self tChap,er9 •Ts' GF i p,� a r/� 111 Valuation
.,,bar(commencing.withS is ]roll) fD i J of Bossiness Any Code)
of Sec He is cu opt therefrom and the be...for the subjects
thalleged esemnot t Any violation F'
-M genion 703 LS by any npplicam fora(Knoll subjects the applicant to a civil penalty'
iornmmorcthan'five hundred do11ua1S500). 101APN AT ION f'""" '• Occupancy Type
01.mi side
- e
will ne the xva.:and the structure is n i ,ad License
doe sale,see 704,La10 3 - UFER Required Inspections-,
owner of ono property
Who
Wilds
o The Contractoro License Law does not apply to an CI p
owner of paois o Who builds or improves e,such
laid who does Sam wink mmxu 104 - _REBAR
or,hruussh has own employees.provide)that such vement mend arc not Intended of
ofiopli i. she.If.however,the building a anent of
is sotto within one year or i .. - '
' It the«vile-buimerxalhave thebuaa<amor n anan<aidnmaaaa«� 105 - ANCHOR BOLTS '�.'.� .•, '--.._. . ':„ ,
imPm.e�mpumir orsae.). prove g 106 - SEWER & WATER I
nce.to 202 = UNDERFLOOR-PLUMBING
G3 1. olvakrorih�peupeny+m«cIdsivelr=tnirr<aias won he.."<aalrrL�toa to --
co,mer he project(sec.mrq.Basin=s and PWfinwions Cusba)The Cour acrers 2 03 - UNDERFLOOR MECHANICAL'! ,1�.
License Low Jots not apply,a an owner of pmpeny who builds or improves Ilamem.
204 - UNDERFLOOR-FRAME-d who.contrets for.sum projems.with a.comramngs)licensed punsanl.to Ile. ..._....__..
- _..__ . ....___._.._._.._ ..._.
Contractor's License Law.
❑lmin enamor undo set, t B'&PeFields a« 205 - UNDERFLOOR'' INSULATION
•Owndi" ... t Dale
301 - ROUGH PLUMBING
WORK
ER'S COMPENSATION DECLARATION 302 - TUB & OR SHOWER
I hereby affirm under,penalty of ar;pryone of the following declarations: 303 - ROUGH MECHANICAL
Cl I have and will ontoi''a'&Aibcb�e nP con ant lu selr.msaae ror wna*er5 3 04 - ROUGH ELECTRICAL
Compensmom, a provided for by Section 3700 of the Lvbor Cattle. f« the
performance of the work forwhicnthisp<,mitisissyeq,,,,, 305 - FRAME
D 1 have and will miiniain Workers Compcniution Insurance,as required by Section 3 06 - HOLDOWNS
ilio of the Iibn:coda for the performance of the wdak for which this ppa;glt,is
307 - INSULATION
ueJ W rLpt n I an seed Pol y n le . � 3o8SEEROCKr.arro
iil I _ .•
v' ERTIFICATIONOFEXEMMUNFROMWORKERS., 3O9 - EX'TERIOR •LATH
eYYP7 '' AnorvlrysunArycEP ::, 310 - INTER'IOR' LATH1 ";` "- ----....--
"'r IThis uain'ai lace)nm yh,<��� p1aW d tle pe,m t s for nn hmMrea dollars _ I 1"
51 W)
Rsal µ3l1
SCRATCH COAT
313 ..----ROOF NALL.. .. _ _. __. ._:. ...,. .. . ......
yip 1 c rtfy th t in th perfpounce f the rl,f w h ch tti.peumi,s Issued.I I nh-
sC.innm employ any Person in any manner.sba%tobecame bjectrotM,Workeri 501 - FINAL ELECTRICAL"ENERGY
''cadcvanpm..aaan a snrcag" ' ,,Date 502 -- FINAL PLUMBING ENERGY_ -
cat _ .•.. ., .. .. .
NOTICE TO APPLICANT If after makingth CrffaatefExemption,you should� 503 - FINAL MECHANICAL' ENERGY
"
ODbecome subject to the workers Cou,s nation piov stuns of the lab«Code.you moo
forlhwithcomplywith suchprevisionsorthis Perniitshanxdecanmre._ol_m. 504 - .FINAL BUILDING-.ENERGY, ._.._ _
F+ rn -y '.' !r '' `'CONSTRUCTION LENDING AGENCY, ' ',"' 505 - FINAL ELECTRICAL "' " 5' ,
I h by m that there i - u t o hooding agency for rhe peifs,mam'ce Ir'
C > 'of the work for is hi,h th perron is ssued l5ee.34397.Civ.C 1 , I.,,. 506 - GAS TEST
'a Lena r " 507 FINAL PLUMBING
..,.Z Lcnileas Address 1 ., �.v:
U p 508 - FINAL MECHANICAL
Io,`,1 certify that I have amd this application and arainformation e that the above infoion is
Is; F. e r I are t comply hab city and countyordinances a tat l mining 509 - FINAL GRADE
C.0 10 building construction,am!h shy andoorrin rrpsentativesafihiscity to mrupon
Q .Q. the boom apopndb npechonpapo. 510 - FINAL PLANNING
y (W) g to sa c aim 'nndk hi hamay!p the way Ctipenmo agamt 514 - FINAL PUBLIC WORKS
V]' lria�b4Cjjd ym�tc�,rys, t peones wh ch moy In ny y c g m. snsd,y� gUypERfSTA,R ( glfN, m,11PLY 'ITH .c I Ilpp�f U/ Issued by: Date ^O
,ureorApphcanvC ntmch .,e Re-roofs
HAZARDOUS MATERIALS DISCIDSURE l
Nrll Nc boot ca t o rum bn'Isting«cupant act «beadle hamNous areata,1 Type Of.Roof -
:nsdefinedhytheCupenmo umep ICode Ch ole 912 and the He hh emM Sof Sy ,y,. t y e �,a . •,
Code Socha
255'2(a)n f - s.'�11,i�,j.a. f` 1 '`•
All roofs shall be inspected,prior.to,any.roofing material.being installed.
5, WdltheapplicantorryturebuldingSkeuP31Uuseequipmentordeviceswhich If a roof Is installed without firstobtaining an inspection,�hagree'•toremove
emit hazard eon t d B ed by theBay Area A Quality M ag em'
/
District } _ _ all new materials for inspection. Applicant understands and will comply with ,.
�Y '¢`"
all non-ponli
I. it source regulations.
, , •
1 have odd the haiidous an hrials requirements under CWpw 6.95 of also
t;6lifom'y Heahh&Sofery Code.'Sections 25505.25533 and 15536.1 undaetarld rha' _ _
ifi I{I in,din tc ,11Y)Jqq etc niton ympo Wily( notify the .,,
C o ts of� 1 ,: I' u: t ii. a c f e n:ficae or
a Y
_ Signature of Applicant Date
-ow n�r=ea-as t te�; All roof coverings to be Class "B" or better ,
�
. c�, a., ra OFFICE