19612 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuMing Pm'eat Identlflutlon PERMIT NO.
Building Addrev: 196 12
22900 Cristo Rey Drive, CA 94024
Owner'.Name: m¢: APpLicATR593CTZ=A
Forum Life Care CITY OF CUPERTINaBUILDING.DIVISION. 6-7-90
Cm�tnaar's Name: Late Nm APPLICATION / PERMIT
VMn Electric Inc. 14134 gUtlgNGp��CA4PLUMBINGMFL AN CAL CATEGORY coven .
Ao,haect/Ergineer. Le.No
HKI6T BUILDING PERMIT INFO
Q ELECTRIC PERMIT FEE
Addoner 553 Mission St. , S.F. PERMInSSUANCE
LICENSED CONTRACTORS DECLARATION E
Iherebydfirmthatl un lk,xn dunderprovblau ofChapter9(mmmen APPLIANCESRESIDFNITAL gDESCRQTION
Ingwlth Seeloo7000)of Dertti.3olthe Bualrmand PmledmeCode,and my
Ikeve b In full d d@e. PANELS
LlarweClaa �° LRs 386973 ' 12.50 Apartment #4 Temporary
Date Conte dor
ARCHITECTS DECLARATION 201-1000 AMPS
oto 7. 1 underotand my plans slug be used n public records OVER 1000 AMPS SQ.FC.FLOOR AREA $/SQ.FT,
wO
Lkerued Pmifnarbnal S)GNSELECIRICAL I F
A
n , .
r<N OWNER-RUILDER DECLARATION SPECIAL CIRCUIT/ML9C c I- „i \,
7'g, - IherubyafBrmtHtlsm nemptfmnthe Comranots Licence Lawforthe — � �
follntywh ape Q115,Bu mea ePr p lops Code:Mydtyor L `[ •
OQi. TEMP.MEI'ERORIOI.E INSf. �s.� �(]�
� muntywhkh requlrnapenNeto mretron,alter,impmve,denugah,ornpair
� anystwetem prior W ib lavame,cubo requlmthe apple nt forsoch permit to (OWER DEVILS d flle a signed statement that he b lfoevad punuant to the pnovbbrar of the 'IDAT
Oar Cantrarim"Lkenu Law(Chapter9(comnrcndngwhh Senknn 700%of DIA- i
30�<
1n3ofthe Bu,inemandl'rdubv Code)orthathebear thbomaM SWAfhm`IG IDOL IT,ECIRIC ALU TION
S the basin for the alleged exemption. Any vidatbn of Section en7WIS by any
<� appgoufora permit sub)aRs the applleant ton civil penalty of not more than OUTLETSSWITCHFSFI)(TURES
five hundred do]"(SM,.
❑I,as owner of the property,or my employee with wages u their sole NEW RESIDFNIIAI,ELECIR AFI'. STORIES TYPE CONSTRUCTION
7� cmnperutood willdo theworkandibestrodurebnat M[Medor offered for
ovie(Svc7py Beano mrdrdusbn h bd ilhe.ainp rstamelaw
�$ don ro,tsuch torn owner ofpropertywM bulmpleympnwwkied that
OCC.GROUP RLS.UNITS
who doasurh workMmregorthrwgh hbownemplga e,prwWed that�rh
improvements are,not Intended oroHered forsale.If,however,the building or TOTAL: 24.50
ImpnovemeM bsoW wlthlnoney<arofcanpldbn,eheavvr-bulldrrwgl love
t"denofprowngthe hedid tWldoriyp fmpurpo,eofuLe.). QTY. PLUMBING PERMIT FEE
L_j L va wvn<r of the property,am eu�hnlvely�trertleg with Ikenred FI-OOD]ONE APN
oontoueton to mreatrutl the project(Sec 7011,Buvinew sM Profesebni Cade: PERMIT ISSUANCE
The Contractor'@ Licosa Law don not apply to an owner of Property who ALTERDRAINk VENT-WATER(EA)
_
builds or Improver thereon,and who contrap
contracts fee such Aokm with -
n. - - FEE SUMMARY
ojnLlxxCLxr(a)gaoled purauard to the Cootract� kw
n Le Law. BACK FLOW PROTECT.DEVICE
1 am exempt under Ser. B 4 P C for thisrenin
Avner Date DRAINS-FLOOR,ROOF,AREA,CONE). SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT a
)MI hereby afRrm the I have a artinate of Covent to self-Insure or a FIXfl1RES'PER TRAP SCHOOL TAX _ N
RECETrtiflate of Worken'Campenutlanlvurana a a cutgkd cvpythereo(L`ec.
lab C.) GAS EA SYSTEM-1 WGA OUIIEIS PARKFEE, Y_ N_
Polky0 WP80408194 CAS E.A. ybTEM-ovERa(FA) REC=#
Co9CnP eman' s un B UIL DING DI VIS ION FEES
Gemmed copy b hereby funLded. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
vrtl0e i ropy b flied with the dty inspection dMalon.'
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE Date RLYCI IM
ANC6 SEWERSANITARYSTORM EA 20CF+T
(Thlasection need not be completed B the SUR A b fm ov hundmf dollen
(MMorlev) WATER HEATER W/VENT/OSCAR ENERGY FEE Y N
Imnlfythat IntheperfomunmofthewakforwMehtMspem tbblued,
I shag not employ any person In any manner an as to become subject to the WATER SYSI}2M/'IRFAnNC -
WarkorYCompenvtbnLawsofCalifornia. Date PAID
-
z 0 Applicant PP NEW RESIDENTIAL PLMB. SQFT.
NOMPI.ICANT:H,ager making this Certglale of Exemption,you Data Revel fit
should bocome subject to the Worker?Compensation provisions of the Labor TOTAL:
CC N Code,youmautfwthw hmmplywithsuchprovblovorthbperMtalallbe
deon,d revoked. _
W CONSrRUCT10N UNDING AGENCY SEISMIC FEE
CL O IherebyafBmnthat there ba mvtruction lendingagevy forthe perform ELECTRIC FEE
M Z ane of the work for which thio permit b tsaued(See Son,Civ.C.) TOTAL 24.50
UO Lender-Name PLUMBING FEE
LLH Lender'sAddmss QTY. MECHANICAL. PERMIT FEE MECHANICALFEE
O W I art ify that l have read thio application.M state that the above Information
fe earini.l agree to comply with all dtyaM county ordinances and state Lwvt PERMITISSUANCE FEES PAID:
} 4 Mating to building coremetim,and hereby authorb<repreaentathv of thio
(— N dty to enter upon the abovcmentbn i Property far WpMbn purpose. ALTERORADDTOMl9M
(We)agree to vve,Wemnify an d keep hartalm the City of Cu pen InaDate .RCCCI HI
V vgaWt liabWtin,PdgmeNe,nista and expevm which may b any wayamue AR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
aga hart said City In o nsyueue of the granting a thio permit,
AIR HANDWNG UNIT(OVER 10,000 CFM[) CONSTRUCTION TAX
Signature of Appll ret/Contractor Date Da-IAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applloM or future building occupant store or handle havrdous HEATING UNIT(TO IM"Bon
material a,defined by the Cupertino Mu Ndpsl Code,Chapter 91;and the Date RC ci Ill
Health and Safety Code Section 255324)? HEATING UNIT(OVER 100,00(l BTI) TOTAL: 1 94 50
❑WImes gond or�ture building Notseegcdeapplicable. VENTILATION FAN RESID>
PP Basd Pa^ MNP ISSUANCE DATE
whkheManage ent air contaminants as defined by the Bay Area Ab P '"
Qu❑ILLY Management Dis❑trkY7 BORER-COMP OHP OR 1W,IXD BTU) C V
No
have rvad the bar ..muteAabnqulnmcnbunderClupter695 of BOILER{OMP(OVQt 100,000 BTIn `' A199n
the Califom4 Heeth&Safety Code,Sectbv 75505,25533 and 25531.I !�I;� O { 1
undcatand that it the building don not currently have aterant,tlat It is my NEW RESIDENTIAL MECH SQ.FT
respomvmgityto notify the occupant oftha Uertar teh muslbe mut
pdorl weofv Certificateof
_ / 4
erorauthortred vgent TOTAL: ISSUED BY:
OFFICE COPY