20722 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
IfioldInj Project Identiflathm PFRMITN0,
Building Add.; n O n n
22900 Cristo Rey Drive,' Los Altos, CA 94024 G G G
ners Name: one: APP13CATR5=9917A
Forum Life Care CITY OF CUPERTINO-BUILDING DIVISION July 17, 1990
contnctd.Name: Cupertino 1413 .Na APPLICATION I PERMIT
VikiLn Electric Inc. C10=386973 BU[LD1NOE"ECiWCALPLUMBING-MECHAMCAL CATEGORY CONTROL.
HKIfi'1�aj� u N¢
QTY ELECTRIC PERMIT FEE ' BUILDING PERMIT INFO
Add. 553 Mission St. , San Francisco 1PERMITISSUAICE 12.00 � ❑
LICENSED CONTRACTORS DECLARATION
I
hereby Wim,that l en lkenaed order pmvblorsof Chapter9(mmmm APPLIANCESRFSDENnAl JOB D15CR11'I'XJN
Ingwlth5eebon 7000)of Dividon3dthe Buane dPmfnY Code,and
Datfictnsebi"bo"
(u Cl0L Etc.# PANES 1Dt 1 -e--, �.-��
LI¢nae(las_CLO-_Loom '1R(,973 `7LV��.IYE -�{`_I`^��.wJl',_
Dae Codnaor
ARCHITECTS DECLARATION 20/41100 AMPS
p�v020 I ondereond try plaa.hall be used as m
public reah, OVER IODO AMPS SQ.Fr.FLOOR AREA S/SQ.FT.
k Llcersed Prerfeubvl SIGNSELECIRICAL
< OWNER-BUTLDEt DECLARATION SPFTUALCIRCUIT MISC
71.., Thereby affirm that fameaempt fmmthe Contractor's License Law f«the /
oo '3 following reason.(Section 701.5,Buseneas and Profmloa Code:My cityor 1
6 7 r.qqqq TEMP.MElT)t OR POLE INST. 1—0.OO
fi rr– 'p9 muntmw rope iciv per me,a6orequt ttr alp hvntfmoWh,arrtpw _
any amaurt prbmentth treses,lionequlrtatuant to the f«aiom of t e POWER DEVICES
O�� fik a signed statement that he b Iloensed pursuant to the peoWbm d the
3 u.� Contractori License Law(C)apter9(mmmandng with Section 70(0)of Did- SWRMNG POOL ELECTRIC
o Aon3 ofthe Busboas and PmfeshmaCode)orNrt he b exempt therefromand AL ANION
the basis for the alleged exemption. Any vicleton of Section 7015 by any
applicant fora permit subjects theapplkant to.civil penalty dna mus than OLMZr&SWITCIISFIXTURES
E live�undred ddhn lX`AN. NEW RESIDENTIAL ELECIR
u I,as owner of the property,or my employees with wages a their sok ��' ` TYI' CONSTRUCTION
I. compensatl«,wl)l do the work,and the structure Is not Interned or offered for 7
G O mak(SLI 7064 Bei
unne and Pdeabv Cade:The CoMh W« e
ncton, Taw
(lj S does rot apply to an owner d property who builds or Improve thereaM1 and ROUP R6.UMTS
C whodmsuchworkhlnm Ul thwgh Msownemplo/en,provldedthat. a
ImpmvemantsammttendedoroHeredf«aele.If,however,theWllding« TOTAL 22.009
Impmwc ntbwldwithlnowyearofcomplebn,theawner-builderwiDl ve
t ben ofproving riot kdM 45
notbuBdorimproveforprposeofakJ. QTY. PLUMBING PERMIT FEE '
L as owner of the property,am exav ely contracting wilt,llmnsed FLOOD ZON APN
do
mntruxtx,to mrnlradthe project(Sm 7064,Buaines and Professions Code: SIT ISSUANCE
The Contractor's License Law does nal apply to an owner of property who
buBda or improves thereon, and who mmratia for such M recta with a ALTER-DRAIN 4 VENT-WATER(EA)
Tdents)licensed puewnt to the Contractor'sLicense Law. BAIX FLOW PROTECT.DEVICE FEE SUMMARY
TI am exempt under Sec B 6 P C for this Ralson
Owner Date DRAINS.11001E ROOF,ARFA,(OND: SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT If
K
[lKhersby affirm the I have a certificate of Casson to self-inure,or a RXTURES-PFR TRAP SCHOOL TAX Y N_
RECEDE r
mrtlfiated Workeri CompewfionlvunnaorsanUi ropy Nenrof 6ec.bClCAS FA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3Dpd°Dky0 WP504081,94 RECEIPT
Cas Ea.sYsrEhi-ovER 4(En)
Com ray Fist man U"_
, BUILDING DIVISIONEF."
-'�ee"in`d ropy Is M'y bmi.n`d. ( cRFwsE/wousnze waslE INTFRCErTOR PLANCHECKFEE
Certified ropy b fBed with the mY IapMbn dW Won.
CERTIFICATE OF EXIEMP1'ION FROM WOR KERS GREASE TRAP PAID '
COMPENSATION INSURANCE �.m SANI.I.,UtY-S'rowu FA. Date Recei (#
(fhb section need nal be completed 0 the permit b f«one hundred down
a1DD)«le:) WATER HEATER W/VENT/RECTA ENERGY FEE Y_ N
1«nor thatbthe person nmdthework so as tobreds permitcboiled,
I shall red empen my peas f any manner so u to become subject to We
WATER SYSTTM/TREATING
W«ken'Compnmatlon Ewa of California.Dae PAID
0 Z Applicant
Z O NOTICE TO APPLICANT:U,after making this Cenifiate of Exemption,you NEWRESDENTIALPLMB. SQF. Date Recel t#
F N should bemmesub�en to the Workeri Compermatbn prewmm of the Labor TOTAL:
Code,you nus forthwith comply with each provisions or thio pemdt shall be
LU > deemed revoked. BUILDING
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL O Iherebyaffirmtlutth mart amrutr dims Mi gagerryforthe dome _ TOTAL, ELECTRIC FEE 22.00
Z anceofthe work for whkh this permit bu
bound 6Sec 3097,Cur.CJ
V O Lendef.Name PLUMBING FEE
IL �- Lender',Addm,s QTY. MECHANICAL PERMIT" FEE MECHANICAL FEE
O W 1onefythet l have read thisappllotbnand state that the above information -
mmrrea.Iagrteto ctmpiy with all cityand muntyordlnamand Yate laws PERMIT ISSUANCE FEES PAID:
} 1 relating to Wilding construction,and hereby authorlae rtprnentativo of thio
f. Z city to enter upon the above-mention i property for Wpeetbt purpom. ALTER OR ADDTO MECH. Date Red t#
_ (We)agree to save,W emnlfy an d keep harMew the City of Cu pen bo
s,enet liabilities,0 dgmam.,caste and e.pems which may in any wayecrve AIR HANDLING UNIT(TO 10,"CFW SUBTOTAL:
aga be said City 1m mesequenm of the grant Ng of this North.
AIR HArmulvc cJNrr(OVER 140)0CF\D CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DI SCIOSURE
Will the app"ot orfutum W Oding occupant Yore or handle havaniaus HEATING UNIT(1010,ODO Inn
material as dell red by the Cu perdno Municipal Code,Chapter 9.12,and the Date Recei t#
Health and Safety CW,SSectlon 7553] HEATING UNIT(OVER 100,0BTiJ) TOTAL: 22.00
Yes 1 INo of applicable.
00
Illthe a ppllant«Tatum bu Oding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) UANCE DATE
hitt,enull 1(acaement iArba?ic lantsadefired by the Bay Area Ab ,•
�oulRy Alaiugemem DiYrlet2 BOILER-COMP OFQ'OR 100p(IO Bnl)
No
Ibave nad the haz ou,matcrlab requWmenn undcrClupter 6.95 of BOILMOOMP(OVER 1DLOW BTV) JUL. 1 •71✓91J
the Glifomb Health 4 S,fcfy Code,Sections Ts545,75573 and 25534.I
urderetand that ifthe Wilding does not currently have a tenant,that itis my NEW RESIDENTIAL MECIL SQFI' (;jhl Of CUD_PI'tifip
reaporom ytonaltythe occvpamdthe requirements which rtaY be met ,
ph to ..1.7 teofocctrparcy.
7/17/90
er«aulho� a apt Date ISSUEDBY:
ennon (, aILe TOTAL
OFFICE COPY