02040082CITY OF CUPERTINO
BUILDING DIVISION PERMIT
CONTRACTOR INFORMATION:
BUILDING ADDRESS:.
PERMIT NO.
-22590 VOSS AV
JUST WATER HEATERS INC
02040082
OWNER'S NAME:
APPLI A I NSU T
.PLEASANT VIEW CONVALESCENT HOS
1764 NATIONAL AVE
O j�67RTb2,
HONE:
(510)293-9901
SANITARY NO. CONTROL NO.
. ARCHITECT/GNGINEER:
BUILDING PERMIT INFO
ELECT PLUMB MECH
IJ CJ L' J U
LICENSED CONTRACTOR'S DECLARATION
I hereby alBmi thin 1 am licensed under provisions of Chapter 9 (commencing
lob Dec I ❑ '
REPLACE HOT WATER S�'1r� WGE TANK
with Section 7ofu)ofDivision 3nnheBusiness and Promotions Code.and myuanse
a:iefall
& HOT WATER BOILER.
seCloxanaerza'.
License Cama Lie. a
Data Cnmracmr
ARCHITECT'S DECLARATION
1 and ... .it my plain shall no used as public recordist
1 Licemed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following mason. (Section 70313. Business and Professions Code: Any city or county
which requires a permit to construct, alter, Imv. prodemolish, or repair any structurePraono
its isaaled theupPlicant for flea
-"_- 4000.._....—_ _
waa impacts such permiuo sm
signed emem
Nat he is licensed poTsvani to Hr provismns of the Cont.cme, Licanss Law (Chapter 9
S,q. Ftr. Floo{Area'. ,
Valuation
(commencing with Section 7000)of Division 3 of the Business and Professions Code)
I ; i ;-• ,.
I •44 -
or that he is exempt tneiefrom and she basis for the alleged exemption. Any violation"
_ _(
of Section 70313 by any applaevns for a permit subjects she applicant m a civil penalty'
•orot mom thin aehundred dml.(5500).
APN Number
:.. .i .•, Occupancy Type
❑I,asownerofaeproperty. „rmyatnplaypepgathwngesealsole compenmtion.
502 - FINAL PLUMBI
G ENERGY
will ne m ezhrk. and He out The ax nut clost a orLaw doe ami apes 7fw4:
d sat and Profusions Cade The Conwcmr's d juju offered Law docs ria apply m nor ,
506 - GAS TE SIZe aired Inspections-.""" b o nT.
owner of propeny Who builds or improves thereon, and who does such work himself
507 - FINAL PLUMBING
err throwsh his awn employers. provided that such improvements art not intended or
uffcFcd'fOi sala:lr; nowevcc fiat tivalein- within one
g or improvement sold within one year or
n
completion. the owner -Wilder will have the burden of proving that he did nm Will or
improve for purpose of agile.).
._ _ r.... ........_. ..... ....._... _._...... _. _.....____
❑1:aowner arshe propeny. vin exclusively ynd contracting
..... ._......__. ..
_.. ." _ .v l',1
e:)The ontmccsto
onswa the pro)ca (5cc 70x4. Business and Profentom Colic) The Conwaor's
Law does not apply to an owner of wbo W lids
-and-whoa cooly
.nod who commcm fLat. ryojertx with a.commaor( se
licensed pursuam.to �He
...... ........_..._.......... - , _ ... _.
ora Licerre law. r
❑lam exempt code,
01 tom P C for His rcvson
�..
Owner D"m'
FINALE®
WORKER'S COMPENSATION DECLARAT&
ION
•" 1 hereby affirm under penalty of pc jury it of the following declarations: -
/t APR
F7if{ 2 y 2002
❑�I'huve and will maintain a'Cenaficam of Consent to selLansurc for Worker's
Compensation, os provided for by Session 3700 of the 9sbw Cad,: for He
performance of the work for which His permit is issued.
+
BUILDING
❑ 1 have and wall not' n Worizr's Cumpemsaiion Insurance, as requiml by Section
V�g''9qpp�
G
3700 of the Libor Code, for the performonce of the work foe which His permit is
Workers Compensation lnsumnde curierand Polity, numbcrate:
Cartier •,: .�('.,' �Pobcy No
r 1.
•, L, CERTIFICATIONOFEXEMPTIONPROM.WORKERS';'
- "-
'COMPENSATIONINSURANCE'�:;,}: '" _
"-' (This section need not hc'rnmyleicd if the pemin is fm one hunemd eollars
15100) or less.)
issued,(
,i.1cmploHatin He peinad,cea.t.mso as
, aI,
1Porwhichudoeermite
shell not employ any person an any manner so as m become subject m He Workeri
Cmurpearailion !a a,ofp I f .Dam
Certificate
INOTICE TO APPLICANTrkarx Cudlt you
'•`tt..` . v .. .0
Gmrmvkangibis ,ni Labor you most
becomesubjectcoin
the Workepr Colons this provisionsll the Labor Code; yodmust
or
forthwith comply wiH'iukh provisions or this permit shall be dermcd revoked.
comply
-'it `CONSTRUCTIO\LENDING AGENCY
1 hereby affirrin that there 6dlllxwLi6a lending agency for.He rjcjfdimanxeL..
'n
•t
ors kr nests perm us:-tta(Ser3097 Cm. c.I "
V \ 1 �s
. Lenders Nnme „ . .• •.. •. `. •. ._ ..... ..
__-
. __ _ . _ ._ . __. _
Lenders Address .,. .
. 1 canary that 1 have read His application and nate that she above information is
cortccc I agree to comply with all city and county ordinances and nam laws at
to building connruciion, and hereby authorize rapbal nwives of Has city to enter upon
the above-mentioned, propeny for inspection purposes; ,,.
IW,j agree so save; indemnify and keep harmless He Catty of Cupertino gig _car
liabilities, judgn¢nu, costs add expenses which may in any way aeeme against suit
City in consequence of the gmminpof his permit.'.;"
r
APPLICA.S7 UNDERSTA?DS ASD, WILL CO?fPLY. w rH A i:.N6X:poiNT '
It . "
'
Issued by: Date
SDORCE'REOULATIONS. •,.'
Signature of Aprrc.VComraa.-,' -- ^ * .:.'; ,-' " ".Dam
1.1 '
i
Re -roofs
HAZARDOUS MATERIALS DISCLOSURE
i;' W511 He applicant or fumrt WddHg occupy t itom or hackle harardws ads'
Type of Roof ... -- - - - —
• J p
as defined by the Cupen ao M rsc pal•cod Chapter9 12, and theHealth e d Safuy
., r,,
Code 'Section 255321aI r
.. ❑Yea, .,,\
'.
1 :.'.`•
.All.roofs shall be, inspected prior to any.roofing material being installed...,,_._...
m�•;W0I the ap or furore building oaupant use cquipmem ordevaces which
If a roof is installed without first obtaining an-inspectiohijragiee to:remove
c1cont
ithuartha air comaminantsasderinWbytlm Bay Area Air Quality Mumgement
Da:art
,
all new materials for Inspection. Applicant understands and will comply_with
°"o - -
ai jals inner, X6.95
all non -point source regulations.
IIhave mail He huallou spina mquiment. Chapter of.He
(Ni4omia Heihh & Sillily Code; Sections 25505. 25533 and 25534. 1 understand that
ties, holdingohregnmcutowuhiaveucnvnt,lin it is mylesIrl sibs tonotary she
-
"
Occupvm of «quircmenm,wfiich man be inn prior, tv islumtt or Cenificne of
:
-» " • ' - ' •'' �'- �,
Signature.of Applicant Date.
.. - „
_
roof coverings to be Class "B" or better' -
Owner or autbori:eg,npem �,":' - ".'-'" ,, ., DataAll