20158 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT.PEN ONLY
Bulldln d
Preet Identiflotion PETLMITNO. -
eaudmgnee"": Rancho de San Antonio
22900 Cristo Rey Drive, Los Altos, CA 94024 O1 I 8 8
. one:
APPLICATION SUBMITYA=r-
Forum Life Care CITY OF CUPERTINO-BUILDING DIVISION', May f5, 1990
Contractor's Name: Lk.Na APPLICATION / PERMIT
Viking Electric, Inc. 14134 BUILDINGQECIAICALPLUMBIN, MECHANICAL CATEGORY connROLr
Archftert/Eng/neen Lie No:
HKIST - •BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Add. 553 Mission Str. , S.F. 1 PEMITI55uANCE 12.00 1:1 fl 0 ❑
LICENSED CONTRACTORS DECLARATION
I hereby sfflnn slut lam llc ,eiuMer provblm.o(Ch.pter9(mnlmmc APPLIANCE&RESIDE TIAL JOB DESCRUIRON
ingwlth SeRbn7tpt10�0)anf Dwidm3ofthe Buatras and Profs rntsCode,and try
I eoaaClanfuT �ddfesc 386973 1 PANELS 12.50 SNF — NW Corner,
Date cnmraaor Temporary
ARCHITECTS DECLARATION AMPS
SCO Iunderstand my pL...hall be used u pubheremrd°. OVERIOOOAMPS 5Q.Fr.FLOOR AREA - $/SQ.Fr.
`j Llren,ed Pmf.lonal SIGNSELBCTRICAL
OWNER-BUILDER DECLARATION SPEC7ALCIRCIIn/M1SC
]E' Ihereby affirm that lam exempt form the Contractor'.Lioeroe Law fee the
F� Q lm.•nngrta,00.(SealenMI-S,B°.mew.edPofealun,CodcAny atyor 1 10.00
�ry rncountywhkhnrq apem wmromcLatter,4 pmve,dermlhh,ormpalr TEMP. OR TOLE INSI'.
q� ^J any.erunure,prior to 10femunce,.bo requlrn the appbcart(mach permh to POWER DEVICES
Li t fib.algned Ratement that he b Iloeaed Pureuant to the prewtsk u of the
Contradore Ue..L.w(Ch.pter9(ce..rng with Stolon 7000)of° Divl- SWIMMING POOL ELECTRIC VALUATION
og Non3of the fhaale .nd Prof.io.Code)orthat he b ecmptlherefrom.M
the bals for the alleged eaeneption. Any violation of S Ion 70315 by an
�^ apptant fora peordtsubjects Neapplicunt to a ctdl penalty d out more than Wn.E1SSN'ITCF�rT H%TURES
fi1dred d&uosC1SM. NE RESmQJ77ALELECIR SQFr.
STORIES M'E OJNSIkLCf10N -
,una owner of the property,or my empbym wkh wagn u their.ole
k < Compensation•w•Uldothe work,and thesbucture b not Intended or offered for
O dale not
apply to a neo and Promsba Cady.The Cordnctols heeom
doo roessurh roan owner property who nem orlmpmvnthertoq.nd
nom^^
who domeuchwohhlmeeUorthwgh Mtaownemplgm,prwlded that.vch OCG GROUP. RES.UNITS
Improvement.are,not Intended oroffend[foreale.If,however,the WlWing or TOTAL 34.50
Improvement hwId wlthln oneyearofeempletion,the ooner-bullderwW have
t rden of proving that he did not wild or Improve fee purpose of daleJ. QTY. PLUMBING PERMIT FEE
L u owner of the property,am exewlwely mntracurg with 11¢naed FLOOD ZONE APN
ournaeton to matmd the projxY(See 70K Budinem and Professions Cede: PFRMUISSUANCE
arue
The Contractor'.LlLaw does not apply to an owner of property who ALTER-DRAIN k VFM-WATER(FA)
Wilde or tnprm• thereon, and who eontnm for each p�okm wth a ,
�ll[�+et.rW ticeneed pursuant to the Contractor'.Liar.Law. FEE SUMMARY,
LJ I am exempt under Sec i B k P C for this rtuon BAIX FLOW PROTEST.DEVICE
DRAINS FLOOR ROOF,ARG,COND. SANITARY Y_ N_
Owner Date RFGFLrI'
t WORIUTAN COMPENSATION DECLARATION FACTURES PER TRAP SCHOOL TAX Y_ N_
I hereby°(firm that I biwe a¢nlB to of Coen to self-imam,or.
ere+rTlgoteofworken'ComperaaHminw oe ora otrtmeio."the.f(See. RFimTI
3800.Lb C)111yQ_ aa GAS EA.SYSTEM-]WG10IfII.E15 PARI(FEE Y_ N_
Ibt Y II�TSOL102 C? 1 CAS FA.SYSfphf-OVER�(FA) RECTUM'.
Com y j'r ry1.Q t r nI BUILDING DIVISION FEES
Ic-Ifled ropy b�er bey tu7nfshed. GREASE/INDUSIRL WASTE INTFACEPTOR PLANCHECKFEE
ropy Is fled Mth the dry inspection divWrxn.
CERTIFICATE OF EXEMPTION FROM WORKERS GRE`SETRAP PAID
COMPENSATION INSURANCE
(Ifib.ectionneed nrah rompleed if the pemJtb/wore hundred dollars SEWER-SANITARY-MRMEA.NIiFT. Date Recei tN
a1007orn WATER HEATERW/VENI'/EECTR ENERCYFEE Y— —N.
Iawymatmme p,rrormanmerthework rorwm,ntwpemdw,;a,ed,
I.hall not employ any person In any manner en u to become subject to the -
WATER SYSIFM/TREATING
Workers'compensatmn laws of�ur«nla.Dam PAID
-
z O PP NEW RESIDENTIAL PLMB. SQFr.
NOTICE TO APPLICANT:If.after makingtw Ccrttlamo/Fxcmptbn,yw Date RCCeI t#
should become.ubjtet to the Warkers'Compeaatwn provbba of the labor - TOTAL:
C N Code,you dost fothwth comp"th ouch pmvlslons or this permh MWI be_ BUILDING FEE
LU ) deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Iherebyamrmthat there lsamnstmctlon lendiegagenq forth,perform
TOTAL ELECTRIC FEE 34.50
7 Z Lonor of nde,the wohfor wNch thio pemdtlsbved(Sec.W,Ch,.C.)
00 I<wer.wne PLUMBING FEE
LL H Iendere Addrtee QTY. MECHANICAL PERMIT` FEE
OW fythat I eenll have read thisappuotmn a M dote that the above lnformaUon MECHANICAL FEE
M Isox—a.I.gree to comply wlth.11 elty.M..,y. rdlearres.nd taut.laws PERMIT LSSUANCE FEES PAID:
>. to relating to wlkling construdler,and herebyauthorlae rep..tativn oftw -
F 0) City to enter upon the a e-rnentlonsd property fee Wpectbn pu�pa.er ALTTRORADDTOMECR Date Recti !A
(We)agree to.ave,Indemnify and keep harmlest eQtyof CupertW SUBTOTAL: 3 .50
V against WbWtl ,jsdgnew,adeaM es wh yinanyway.eeue AIR HANDLING UNIT(TO 10,000 CFM) '
-galv d in consequenceo the nhn
Permit. AIR HANDLING unTr roVFR 10,000CIT1I CONSTRUCTION TAX
�SjjrC5 I u6eefAppllant/Contract- to EkTiAUST EIooD(W'/Duct? CONSTRUCTION TAX PAID:
LIZARD; TERIALSDISCLOSURE
Wmtheapplkamorfa UdingoavpantatomnrhadLeh.aardeus HFATINCUMT(TO100,000BTU) Date Recei HI
material a defined by tW Cupertino Municipal Code,Chapter 9.1Z and the
urathamsafetycod,sectio, s ( ? HFATINGUNTT(OVER100,000BTU) TOTAL: 34.50
❑Yrs HN, A jpq'J?J�r�i ,T�Ly �-a,
Willthe mppllammtuhureMiml_ng eceua sequipmeNadevim VENTILATION FAN(SINGLE RFSID) ISSUP I,�C.VATE
which emit h.aardous air contamirumta a°defined by the Bay Arca Air
® IityManagement District? BOILER-0OMPOhm OR100,0(OBTU) 1990
y Yn �Na AY y
hive read the h.l oud materials requlremenb under Chapter 695 of BOILER-NY3(OVER 100,000 BTin M
the Gtf.UHeathkSafety Coda Sectio 25505,25533and2SSU. I -
urdemndthatlfthewfiding dootot currently have a tenant that It b my NEW RESIDENTIAL MECH. SQ.Fr.
nmpoalbllt tono,Ifytheoccup°nt fthe beme whtehn.utbemet c1ty Gf (`twgr*vry
pdorto"nee of a Certlfiate of
of a Certlflate of0 p '
Own or authorirrd agent Dat° ISSUEDB
TOTAL:
OFFICE COPY