19611 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
fluilding proixn Idealf"tlon 7 PERMIT NO.
Huilding Addnn: �os-_A]ses19611
Owns" 22900 Cristo Rey Drive, ,• CA 94024
. area, one:
Forum Life Care CITY OF CUPERTINO-BUILDING DIVISION -
CootTaeux',Nar¢: Lk.N. APPLICATION / PERMIT 6-7=90
Viking eInc. 14134 BUfLDINGE,ECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL If
Archkeet/Engnrser. Lb.N.
HKI&T BUILDING PERMIT INFO
Q ELECTRICPERMIT FEE
Address: 553 Mission St. , S.F. PERMITISSUANCE � � ❑
LICENSED CONTRACTORS DECLARATION
Iherebya(firm that l am 11mseduMei,pmvW..fChapter9(. APPUANCES-RESIDENTIAL g -
IngwithSeGbn700P)of Mvidm 3o/the Budnemand ProfiessionsCod,ii.deny
liven:le In full f d effect PANELS
6Di¢nxclase Cori
eartorUP TO 2WAMPS 386973 12.50 jApartment #2 TEmporary
AACHnECT'S DECLARATION 201-1000 AMPS
WrsO(y Zp Iurdentard n7 plane nha8 be uad republic nmrds OVERIODOAMP9 - SQ.FT.FLOOR AREA $/9Q.m.
!0 Licensed Pre(es. l SIGNS ELECTRICAL ' 1
R a N OWNER-HUILDE(DECLARATION SPECIALCIRCUIT/M
4 I hereby amrenthat l am exempt fromthe Contractor's Lheme law for the
Fpp pp folluwing reason.(BMIm,70315,Busing and Pmf®ism Code:Any tlty mr
L cvuntywh"requl apem tommtruMOter,Impr ,dem h,orrepar "�`(p'METFAORI'OLE INST.
O`a anystmciureprbrtoIts 6srarcgalso requ4ntheappllmtfor auchPermit to POWER DEVICES, DATE
IOe a signed statement that to 6 Hansed pursuant to the pmvidom of the
7 vs� ContraGorbLice.Law(Chapter9(mrrvrcneina with Section 7000)o/DM- SZypdhq NG POOL.F],ECIRIC
��5 don3of(he Budnessmd ProleeebroCadeJ orthat he6e,emptthentromand VALUATION
<v the Was for the alleged exemption. Any violation of 5edion 70315 by any
applicant fora permit sub}eefn the appBcaes
nt to a evil penalty no y of nmore than OUILETSSWIICHFSFTXTURFS
w rave undrad 00)
dollars(55 . � NEW RF9DFMIAL ELECTR FT.
�1,as owner ofthe property,or my employees with wagesastheirsole SIORIM TYPECONSTRUCTION
mmptruanon,w ldothewank,andtheamctun6netinteMedor offered for
psale(Sec044,7Budro,and Pmlessbm Code:The Comratlots U..law
S$ does not apply to an owner of pmpertywho bulldsor improves thereoq and OCC.GROIRa RFS UNITS
who doessuch work hhnsHurthrough hisownemployers,provided that such
impmvcrrcnts arc wt Intended oro/fered fm Sala.IL lu wever,the W llding ur TOTAL: 24.50
improvement lased wkMnomyearofc¢npletbn,theowtnr-bullderw111 have
tljLpurdenofpmvingthathedm notwudorimprovefmpurposeofsale.). QTY. PLUMBINGPERMIT FEE
LI L as owner of the property,am esbslvely couracting with Ilremint FLOOD 7DNE APN
mnVactors to mmtmci thr projed(See 701/,Budoraard Pmferbm Code: PERMIT ISSUANCE
The Contractor's Lieerese Taw does net apply to an owner of property who ALTER-DR,UN4 VENT-WATER ffiV
Wilda or Improves thereon,and who mntnRs for such p(ojects with
ryRS(�ctor(e)heersed Pursuant to the CmtnctN.License Law. BAIX FLOW PROTECT DEVICE FEE SUMMARY
LJ I am exempt under Sec B k P C for this mve
anOUTSIDE FEES
DRAINS FLOOR ROOp,AREA,GOND. SANITARY Y N
Owner Data RIxFR'T Y
WORK]NAN COMPENSATION DECLARATION
F11hereby affirm thx 1 haenose - on,maFD=RES PER TRAP SCIiOOL TAX Y NHesteofWorkers Cwnpewtlms Imuran¢m a uMifkd appy thenal Qec. ��0
CJWP8040GAS PA.SYSTFM-1 INC40UII.EIS PARK FEE Y_ N_
GAS FA.SYSTEAOVER4(EA) s rev F,�YPIIIHi1Im BUILDING DIVISION FF.FS
�CedIn,
ropy la hereby famished. CREASE/INDIISIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy In filed with the city Impectloo division.
CERTIFICATE OF EXEM MON FR OM WOR KERS GRFASEIRAP PAID
COMPENSATION INSURANCE SEWER -STORM FA.2t%BT. Date Rcoci t#
Oh6eectbn need red be completed lithe permit6fmom hundred dollen ENERGY= Y N
($10D)or leu.) WATEI FffA1FR W/VFM/E,ECTR —
I eartify that In the pedomun¢tithe work forwMeh this permit Is issued,
I shall not employ any person In any manner no a to become subject to the
Workers m
'CompeatG
lon l�sr of lHmlaWATER SYSTEM/TRGnnG
ana .Date PAID
-
zZ AppHt NEW RE4Dt2-mAL PIMB. 9.�.FT. Date Remi tM
Z O NOTICE TO APPL)CANT:If,after making this Certificate of Exemption,you
should become sub}at to the Workers'Comperaafun n prnvbbm of the I�r TOTAL:
U3
Code,you=at forthwith compny with such prov6bro or this permit 0.11 be
deemed revoked. BUILDING ME
LUCONSTRUCTION LENDING AGENCY 5EISMIC FEE
d Iherebyafnrmthat then ba mrutnuctlon loMingagenry for the pedomm ELECTRIC FEE - 24.50
7 = an¢of the werkfor which this permit 6 blued bee 3097,Civ.C) TOTAL
V O Larder.Name - PLUMBING,FEE
IL H Lender.Add� QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I¢rtHythelhavenadth6app"wnardsatethattheahoveinfor oo
S in. eet.l.greet.complyw
(A khallehyand.etyonllnanorsandesitelaws PERMIT LSA)ANCE FEES PAID:
>. resting to balWing mruwctI.,and hereby authodr expreseruMNn of this
F = &y to enter upon the above-mentioned property fa Wpectbn purposes. ALTER OR ADD TO MECH. is¢ ReCCI IN
_ (We)agto save,Indemnify the emnify an d keep harmieCity of Cu pen fro
ag.hua liabilities,judgments,rode and e.pemes which may N any way a. AIR HANDLING UNIT ITO 10,000cim) SUBTOTAL:
aphun sand City in mneequenee of the granting d this pemdt.
AIR HANDLING UNIT(OVER 10,"CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date IXHAUST HOOD(W/DUCn CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE -
WBltheappllam or future building o¢upant dine or handle harardoun HEATING UNIT(TO 10D.ODO BTIZ Date RCCci t#
materhl a defired by the Cupedim Muructpal Code,Chapter 9.IZ and the
I halth and Safety Code Se Ion 75532((.)? HEATING UNTT(OVER 100,000 BTU) AL:
❑ Yes MN'o NOT APPLICABLE
24.50
Will the applicant or tum building orruNnt use equipment ordevicrs VENTILATION FAN(SINGLE REMD) ISSU ATE
whicheMthaarentinarwawasdenned bytM Bay Area Alr I `I 1 (j
Quality Management
Dentin? gpn MIT OR 100,0(0
Yes F�I No Gil HT10 l�9 J
el Fl YNo 1
have mad then ow naterlab rtqubcmenb under Chapter G95 of BOILER{OMP(OVEt 100,000 B'fU), 1
the Ulifomla Elakh k Safety Code,Sectbro 2550.5,25533 and 75534. I ^4, as„_�.yw
uMenu.ndthat lithe building does not mrxntly have a tenant,that It 6 my NEW RESIDENTIAL MLCH. SQF7 `JI`Y ot L_I_11Rrp W_{L�6
responsibility to notify the occupant of the berrc hich must be rrrt
prior to coda Certllkate of
rorauthodad agent Date) ISSUED
TOTAL:
OFFICE COPY