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19608 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY Buildin Pnobd Idcntlflatlm I PUIMITNO. Building Add.: RANCHO de SAN ANTONIO 19 6 O 22900 Cristo Re Drive Los Altos CA 4024 `+ r•Name. one: Forum Life Care - CITY OF CUPERTTNO-BUILDINGDIVISION • emtnctor'a N.me: Lb.No: APPLICATION /PERMIT Vikin Electric, Inc. C10-386973 BUIllNNGFm.ECTRICAU'LUNlmNGMFLHANICAL CATEGORY CON TROLI Archhen/Fnglrcer. Lie.No: HKI & T 5383 QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO . Addr 553 Mission Street San Fran. 1 PBZNMISSUANCE 12.00 �. LICENSED CONTRACTOR'S DECLARATION Ihe,cehtlambemmedunder WlmdChaxnmmc APPLIANCES-IANCESAE9DEM7AL InghScticm70DD) Division 3ofthelluslrcacd ProfeealonsCode,and my line.In In Fufdf deffect PANELS m,.....6R3tR71 Lianas Clow_L y_�Llc# 386973 r-d�dl7 4'^ Dale Gadractor 3 Lm m m ANIps @ 12.50 ea 37.50 ARC1f1TECTS DECLARATION WI-l()0[IAMPS pQ!07dCC I uMemtard my plam.hall be used as public records. OVER 1000 AMPS �FLOOR ARFA (� $/SQ.Fr.- E od U Licensed Pufe®brcl SIGNS ELECTRICAL «<< ul OWNER-BUILDER DECLARATION p G SPECIALCIRCUIT/MBC �y -P - IM1erebyaffirmthat l am eumpt from the Cmdra m`e Lie.Ww for the cO fogowing rearm.(5e m703lS Bu.lnmaMPrormbra Co r..Mydtyor m O 1 TFMP.METERORPOLE INSF. 10.00 S ` 0� C til F� muntywhid rtqubnapermim tomwruct,almer,lmprwe,demoWh,arrepatr / g 4 anystm=mprimtolbbsuame,alnrequirntheappBantrorsuchpermhto ppWQt file a algnod•atercent Fret he Is bansed purnant to the pnwisbm d the / �h O uu.r Con3ofthe Lberae dl',d.W9(mmmerin wNh Scdinnhemfmf and 3O sh,, the Buslnmvud xemptbuCode) watt n of esertryt the .5 by and VALUATION the Welt for the alleged exemption. Any Wdatbn of Section 7m15 by any J 1p— <� aPPBant(or•permR abjn4a thcappecanttoa tldl penaltydnct moathan O c, Ove undrad dolt s%SM. �I,u owner of the pnporty,or my employer wkh wage a thein wle NEW AL ELEC.TR �f T STORIESTYPE CONMUMON F compew m,wllldotheworkandthearmtl mbrctbterdedor offeredfor psale(see 7014,Busbies and Prdmbra Code:The Contractors Lice.Uw $ don not apply to an owner of property who binds or lmp,ovn thereon and OCC.GROfJP RF5.UNITS himselfmthrough hb ownempleyees,provided that mch Impavemertn are rad Intended oroffere7(meals.Il however the bulldbg or TOTAL: 59.50 ImprvvemadbsaldwR oveyearofcompletb tho ner-b WerwiU have t rdeno/pmNngtna head netbuue or bnpmve fapurpo.e ofeale.). QTY. PLUMBINGPERMIT FEE Lj 1,as owner of the pupeny,am ,s I alwty contrxting with licensed Fl.00D ZONE APN contractors to untrue the pmjM(Scc.7014 Sualnm and Pmfmbu Codi PERMUISIIANCE The Contractor.Licenne law din not apply to an owner d p,.,ny who ALTER-DRAIN 4 VEM-WATER(FA) bulida or Improws thereon, and who contracts for such pWjgr with a T.t cta(s)Bansed!pnrwaottothecmtradQ.LRenne Law. BAOC FLOW PROTECT.DEVICE FEE SUMMARY I am exempt under Sec thio rcaw B 4 P C for n DRAINS FLOOR,ROOF,AREA,COND. SANRARY Y_ N_ f Owner DRAINS. RECEDrF# WORKMAN COMPENSATION DECLARATION FI)(NI0'S PER TRAP SCITOOI.TA% Y_ N_ Fit nrreby atflrm that I have s mmileare,of lona nt to self.maum or• _ RFfFBf# wiI,L.bC_)cerificateof rkelR��gpyQepkt)pp lysyrana araanlf4d mpytherm(Bec. GAS EA.SYSTEM-11NCl OUTLETS. PARK FEE Y N 3600,hb C.1 MYOV411251 x14 Policy# RECEI T# Co ray rad-- GAS FA.''YSTFM-OVFR4(EA) BUILDING DIVISION FEES ECemied copy b hereby filed Uhe city CREASE/INDUSIRL WASTE DMRCEPTDR PLANCHECK FEE �Cenined copy b rued tate we dry wpectbn aidsim. CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID COMPENSATdiftON INSURANCE SEWFIF-SANTFARYSIORM E.A.700FI' Date Reoei t# (D)orI ion need nct bcaarnpieted BtW pond[bfmorchundred doBara p100)mfyth WATER HEATER W/VEXT/ELECTR ENERGY FEE Y N Imnily the loth.per(ormana o(the wok for whiN this pemdtbh�ed, I h.11 not employ any Peron In any manner an u to become subject to the WATER SYSTEM/TRFAnNG O WorIucVCompen.atbn Ww.of C.IlfomU. Date PAID Z 0 PP NEWREHOETMALPLMB. _ SQFT. Date ReoeT t# NOTICE 7O AI'I'LICAM:If,after rtakl�thl.CenBlate of Exenrnpbn, F N enmla become nbjenbtne worker;Campeu.tlm pmwbn.armee T.aybor TOTAL Cade,ym resat Imthwth comply with aurh prvWbm ar thh perMt.M1all be � > deeed mrevoked. 1La CONSTRUCTION LANDING AGENCY . SEISMIC FEE 0. Ihemby.fnn„thattnemla.communion lending agency for the pedorm, - TOTAL: ELECTRIC FEE 1 7 Z dna ofthe wonkfon which thio permB b blued Bee 30 Y/,CN.C.) 02 Lewer�wns PLUMBING.FEE LL F I.Mee.Addreu QTY. MECHANICAL PERMIT FEE WIof.ytgleaov<eomepdythwhapap"tytba, racod unttyetohatthuenacevan +ate MECHAMCAL O FEE_ laws PERMIT NUANCE FEES PAID. NMeting to building construction,and hereby authodu reprexntativn of thio = city to enter upon the aboscmentbned property for bapectbn purpose. ALTER ORADDTO MECH. Date Retei t# (We)agree to cavy Indemnify an d keep harmlm the City of Cupertino against Wbith",�adgnsnts,ensband eapeun whijWnvybanywayamue AIR 7iANDLINC UNIT(TO 10,000 CFM) agabut denybmn.capueria or the Ing permit. SUBTOTAL: �j r ee v AIR HANDLING UNIT(OVER 10,mB CFM) CONSTRUCTION TAX 51 tuneof Appeant/Cmmranor Date FXHALISTHOOD(W/DUCT) CONSTRUCTION TAX PAID: HAURDOUS7t�AA IALSDISCLOSURE' Will the app0ant a future butAding occupant stone orrandle havNous HEATING UNIT(TO IN,000 BM Date RCCCI t# mat lasdefl a bythe Cupeniw M.Ndpal Code,Chapter9.17,endthe Hearth aM Safely Cade section 75532(.)7 HEATING UNIT(OVER 100,000 BM TOTAL: n Ya No Olthe appOanta No VFNIILADONFAN(SINGLERESID) ISSUfjNCE DArE hkh eMm havrdaus air mniaMnenb rue dArcd by the Bay Anes Alr '(lp��_VI lily Management DblrictT BOILER-COMP©FII'OR 100,000 BTU) Yn :a � 6.A' Tuve read the M1au materiab requlremcnb under Chapter 6.95 of IIOTLBR-N /�, MP(OVPRIW,OCD BTU) �1/— the GlBomla Fleabh 4 5afemy Code,Seabrn 75505,75533 and 75534. I 1 undustand that lfthebuOdlngdoetruxarrmtly h.w.tenant,that Barry, NEWRESIDENITAL M.CR SQ.FT. respmamOBy to nctuy the occupant of the requirementswhkh must be prat N prior to los ..of a Certificate of 0.N ray. 1 Q��s Ownerm authorised agent Dale TOTAL ISSUED BY: r T OFFICE COPY