19610 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm4aa Wmtillurion Ir} T19 610
Bulldmg Addms: G
22900 Cristo Re Drive, — o�� CA 94024
• aces. one. A A
Forum Life Care CITY OF CUPERTINO-BUILDING DIVISION .. 6-7-90
Comador,Name: Lk No, APPLICATION if PERMIT
Viking Electric, Inc. 14134 BU LDINGFlECTR G4gUMBINXIM[CHAMCAL CATEGORY CONTROL
ArchXttY/Engineer. Lk.No:
HKI&T BUILDING PERMIT INFO
QTY ELECTRICPERMIT FEE -
Add. 553 Mission St. , S.F. PFRMITISSUANCE �
LICENSED CONTRAROR'S DECLARATION
I hereby afbmthat lam licm•ed under pm Wmaof Chapmr9(mmmenc APPLIANCES-RESIDENTIAL
IngwlthSeebn70DDo(Dlvl m3ofthe BusinesmdPmfad Code,and my JOB DFSCRU'IION
license I•in(u ,nd PANELS Ip_ J` P_ a\
Lice.Cla. sit¢ 386973
t
Date Gardnctor 12.50 COMMUNITY TEMPORARY
ARCHITECT'S DECLARATION Ml-ITO AMI
q
a07' 1undereard my plarmshall be u,ed u public record& OVERI"AMPS SQ.Fr.FLOOR AREA S/SQ.FT.
q��+WWWO
Fi Fj Llcewed Prefe.bnal SIGNSELE)CTRICAL
Gfn OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC E D ' N
I hembyafflrrethat I..e mpt froenthe Connector'•Llce eLaw for the
9F following reason.(Senm
l70315,Bue.
alnaM Profe.bv Code:Anycityor TEMP.ME1TR OR POLE)NST.
Fy muntywhh requ aKe toms d,Ol r,bmpr ,deanlbh.ormpair T
a[ anyeroenm prior to It fsaanee,alw requirnthe appllantfoach P'^r'X to POWER DEVICES /
${K file s signed statement the he Is ikxosed puraant to the proWbw of the
Cointracuir"Lice.$SOS dan3&thee Busines ebSection d ProfeearaCede)oOhrt he bexemptlhe�rtfromneM SWH.IA9NG R70L OLCTRIC LUA
the Wea for the alleged exemption. Any violation of Section 7m15 by any OILL SWITCHESSFU(TIIRFS
applicant fora permit ab)ect•the applicant to a evil penaXyd no monethan
R flv undd dollenW
% . NEW RESIDENTIAL ELECTR AFI. STORES TYPE CONSTRUCTION�1, ye
,s owner of the property,or my employees with wages u their sok
comp raelca,wWdo ilte work,and theeroctim brat Wended or offered for
D sale Sec 7DL4,Bushes and I'rdeasbru Cade:The Cormactur•Llaerue law
don not apply to an owner of property who builds or imprwes thertan,and OCC.GROIIP R6.UNITS
ee.• whodanachwork hlmeelforthmuo
gh hlswnemployeea,provided thatiech '
Improvement are not Intended oraffered for vale.K however,the WIMmg or TOTAL 2 .50
Improvement bold withinoneyee.fcompletbn,the nvner-0 ilderwW have
t Nen of proNng the M dM not build or improve for purpose o/Bale.). QTY, PLUMBING PERMIT FEE
Lj L as owner of the property,am essbevely contracting with licensed FLOOD ZONE APN
contractor.to mrWacttk pmjM(See 70µBoma•ami Prde.lon Cede: PERMIT ISSUANCE '
The Caeector,Llcewe Law does not apply to et owner d property who ALTER DRAIN k VENT WAlIIt
Wilds or Imp.thereon, and who contracts for ach pto(eeb with a
g2tuactor(•)Ilawed pursuant to the Contractor'•License Law. FEE SUMMARY
LJ I am exempt limier Sec B 6 P C for ink re.. BACK FLAW PROTET.DEVICE
•
DRAINS FLOOR, A,CON
ROOF,AREA, SANITARY Y_ N_Owner Date RECQIT Y
,,--ma;(yy
WORKMAN COMPENSATION DECLARATION FT%IiIRES PER TRAP SCHOOL TAX Y_ N_
LLfBateof afRrrn that I have•certlRam d aaaaent to opytwrt,ora RECEIPT R
mNliot of Worken'ConpesaHonlrmuencemacertukd copythuaof(Sec. GAS EA.SYSTEM-1 WG4OUTLEIS PARK FEF Y N
§0 ab c) WP 80408 94 RECEITrTa
ray �man�''^FIISid CAS EA.SYSTEM-OVER 4(EA) HUI LDING DI VI SION FE ES
CenlflM copy b filed turdahed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�CertNed copy b pled with the city ispMbn dlvW m.
CERTIFICATE OF EXIEMPITON FROM WORKIMS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWEF SANHARYSTORM F.A.2DOFT Date Reeei til '
(TNaaectbn need not W completed B the permit b forow hundred dollars
31a0)orcertify
11, mENERGY FEE Y N
Irtlfytlut the pedN
performance work forwch tNtb
s pemnitaed, WATER FffATER W/VEM/EI.ECTA
I shall not employ any penin In any or,n.to became abed to the WATER SYSTEM/TREATING
workers'Compenaelon Laws of Canford,.Date MPAID
Z
O Z Applicant - NEW RESIDENTIAL P B. SQ.FT. Date Recei tp
NOnCE TO AI'PI.IGM:IL aArr nuldng reds CertRloted Faempion,you
should become abFct to the Warkeri Comperuatkn provbbv of the IoW r TOTAL:
F N_ CMe,yau nue forthwith comply with such provleloosorthb permit dull le IN
> deemed revoked.
d G FEE
CONSTRUCTION LENDING AGENCY SEISM) FEE
I hereby afflmnthat there b•mneactim loMing agency for the perform ELECTRIC FEE
Z ante of theworkf=wt hthbpermitbbad(Sec3047,C1v.C.) TOTAL 24.50
V O LeMer.Nene PLUMBING FEE
LL F- Leadcrb Add. QTY. MECHANICAL PERMIT FEE
O w Ianvythalwwe thioappuatbn,MBtatethattheabovemiom m MECHANICAL FEE
a bcorrcax.l,grteto comply with sn dtyaM muntyordmanmand sate lawn PERMIT ISSUANCE FEES PAID:
I- relalingto Wlldmgmrmroction,aM herebyaathobbeb
mpreaentafiwofthis
F = city to enter upon the abovrmentbrcd property forapen purposs. ALTERORADDTOMFLH.ee Date Reeei Ill
_ (We)ago"to save,Iodmkeep eN/y and p harmless the City of CupertW
agalrmt llabiuHn,pdgmeeB,msi•aM expecte which m,ym any avayamue AIR HANDLING UNIT(DO 10,"CFM) SUBTOTAL'
against Bald City In coaaequ ence of the S.miry d this permit.
AIR HANDLING UNIT(OVER 10,000 Cm CONSTRUCTION TAX
Slgrawre of Applicant/Contractor Dat EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding ocmpant atom or haMle buvrdous HEATING UNIT 90 IOO,GDO RTU) Date Recei ted
nutcrlal as defined by the Cupertioo Mu Ncipal Cede,Chapter 9.11,and the
I le,hh ami Safety Cade Section 25532((.)7 }EATING UNIT(OVER ID0,0D0 BTU) TOTAL: 24.50
❑ Yea U No NOT APPLICABLE
Will the applicant or hawre WBdingo pant use equipment or devices VENTILATION FAN SINGLE RF5LD) ISSUANCE DATE i
which emit haurdoua ab cvnlamW rat as deflnrd by ted Bay Area Air
• Qually Management lHerW7 BOEERcomp(3HP OR 100,=BTU)
Yn [:j No' PAID
Nve read the haramotu materials requirements under Chapter 695 of BOILLILCIJMP(OVER 100,000 BTT))
the Gllfomm}IeaW h Survey Cede,Section 25505,75533 and 25534. I
uMertaM that i(the Wudmg dem twl amently have a to rat,that ltb my NEW RESIDENTIAL MECH. SQ.ET JUN 071990
rnponlbuity,to notify the conapant d the me Lmust timet I
prbrm once daCertl tear
mer or authorized agent - ee ISSUED BY: �'e1>•
TOTAL ,t
OFFICE COPY