20723 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildln Prided Identlfkatlun PERM 7NO.
Building Addw: 20723
22900 Cristo Rey Drive
Phone:
Forum Life Care CITY OF CUPERTINO-BUILDING DIVISION
Conbaddn Name: Lie.N. APPLICATION / PERMIT ,l> 8-13-90
Viking Electric 14134� CATEGORY CONTROL.
BUII.DINGI].FfIRKALPLUMBIN `^"""MCAL
ATf/Faglnesr. Idc No:
HRI6, 1 BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE '
Add. 553 Mission St., SF,.CA PERALTEISIIANCE 12.00 bi� PLUMB m
M1LICENSED CONTRACTORS DECLARATION
I hereby affirm that l am peensed under provtslen.dChapter 9(mmminc APPHANCESRESIDEMTAL JOBD N
Ingwlth Sectbn70E0)of DMz1on3 ofthe Bust and Pr&nud uCode,and
ilan I.1.mil laud effeet. PANELS COMMUNITY TEMPORARY M.
Llan Clam' Lk-a 386973 12.50 #2
Date eon<raaor —UP TO 2DO AMM
ARCHDTCFSDECLARATION 1-1 MAPS
flZ I understand my plaroehall be used a.pubucrecmd.. OVER 1000 AMPS SQ.Fr.FLOOR AREA S/�.FT.
p0�yCOC
Fi y Llcenxd Prd.ional SIGNSELECTRICAL
<6 OWNER-BUIIAER DECLARATION
7F, IhescbyaHlrmthetlam exempt Irmo the Contratlor'.Lion Law fee the SPECIAL CEtCUIT/
mEN
6 0 �y fallowing re..(Seal.7.15,Rusin®and Pmfedoru Code My city or gFMP.METER OR -
FE43 muntywhkhrequMapemYttow Tact,aker,impm ,demolbh.ormpalr
3 any.trueture priertolts baarse,abo requlm the appllont f«ach permlt to �RD��
Ofile.mgned staterreot that he b Ileen.ed pur.uant to the proviu..of the T
u. Contractors LbenLaw(Chapter 9(mmmendngwithSection 7000)olDIW-
30� a Rlolthe Businenand Prdmbm Code)orthat hebexem therelromard SWAUUNG NIX' VALUATION
Q 5 the bids for tb dI ged exemption. Any violation d Sedbn 70II5 by any
ppllnnt for.pernut abjecla d e applicant toot dvll penalty dnot more than
hundred dollars(SM. NEW, D
�? "1,a.owner d the property,or my,employee with wages a.their sok 'SQ'Fr' STORIES TYPE CONSTRUCTION
compensation,will do the w«k,and the aWRure h rot Intended or offered for
Ovk(See.7041,Boalnenand Prdembru Code.The Comrade.Lice.Law
('',I f✓� don not apply to an owrcr dpreperty who builds or improvet,thereon,and OCC-CROUP 112S,11M15
C• whodoeevuchwork hlvmelforthrwgh hi.own emplaym,provided thatwch
Improvements are not Intended orofferea f«wle.If,however,the building or TOTAL: 24.50
improvement lawld wkhNoneyearofcompletbn,d,e ownerbuilderwW have
t rden of proving that he did not Wild or Improve fee purpo.e of aide.). QTY. PLUMBING PERMIT FEE
I,an owner of the property,.m exclue vely esntrading we.hand FLOOD IDNE APN
mntad«s to mvlruet the project(Sm 7044 Businem and Rofes.bm Code: PERMIT ISSUANCE .
The Contractor.Lloe.Law don nes apply to an owner of property who ALTER-DRAIN 4 VENT-WATER(FaV
Wild.or Improve[heron, and who mmrad. for.ueh psW)rc. whit,. FEE SUMMARY
�P «
rtor(r0ilnaed pur.oant to the Contractor's Llan Law. BACK FLOW PROTECT.DEVICE
Owner Doe
LJ I im exempt under See. B k P C for this reason -
DRAINS,FLOORROOF,AREA,COND. SANITARY Y N_
RECEIPT I'
1g0�� m ve WORIQ.IAN COMPENSATION DECLAN RATIOF0(n)RES,PER TRAP SCHOOL TAX Y N_
q�I hereby affirthat I ha •certificate of cant to.el(-Iow «a, • RIX:FS'f a
aaificate ofWorkP804081– nlraurana«a artifled ropy thereof 6ec. GAS EA.SYSI.EM-I INCA OUTLETS PARK FEE Y N
3oikyIt c.) HP80408194 - 'RECETPI'a
1'dkya GAS G.SYSIFM-0VEt4(G) '
Com ey e.nan T
s_ rod BUILDBUILDINDIVISIONeDIVISIONFEE
DIVISION S
MCer,med copy ts herebytumCerllRed copy with the ry cidty lmpMbn dhdatm. GRLA
EASE/LNDUSIRL WASH:INTERCEPTOR PNCHECKFEE
d.
�
CERTIRCATE OF EXEMIPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE Stiy,,pTyygM.I.nItY-SroRM G.yTa[,-r Date Reccl t#
(T1d..ttlbn need not he completed lithe permit ts!«one hundreddollane
al Iartifyth) WATER HEATER W/VENT/E,ECTR ENERGY FEE Y N
I e)er le that In the pedornance of the work for wMch this pemdt ts blued,
I.hau nm employ any p,.in any manner n u to become subject to the WATER SYSTEM/TREATING
Workeri Compematbr l,,w.d Callf.la.Date PAID
'OZ ' Applicant NEW NEW RESIDENTIAL PLAfB. SQFr. Date Re i Hf
Z Q NOTICE TO APPLICANT:1L after aking thio Certificate d Faemptbt,you
.hould bemms abject to the Worker'Compematlon provWom tithe Labor TOTAL:
~ N Code,you rru.e(orthwah comply with ach proWbm orthts pemd[.hallhe N
y deemreked.
ed vo
CL CONSTRUCTION LENDING AGENCY SEI IC FEE
Z Iherebyaffirm G FEE
LLI that there b a mmtmdtw lendlog ageney for the perform TOTAL 24.50
an of the work for whkh thb pemdt l9lsaued&c.3097,CN.C.I ELECTRIC FEE
U O Teter.N.me - PLUMBING FEE
LL F Lendee.Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
I¢difythatlhawaadthlaappllotbnand patethattheabnwouturneuon
O W
4 l eoned.Iagreetocomplywltu dd
h. ryaenuntyordir,ocosand aw.atelaPERMIT ISSUANCE FEES PAID:
} relating to Wilding comtmctlne,and hereby authotrUe reprexntitWn ofthl. '
=
city to enter upon the abovtmentbred Property fee Wdb
prn purpose. ALTERORADDTOMBCH.
(We)agree to saw,bidemnily an d keep haurn].the City of Qct pertiro Date Revel the
(), egaWt blurts,jud ran,mots eapemn whkhmaylnanyw.ya. AIR HANDLING UNIT(r010,000 CFM)
SUBTOTAL:
agal Cayb emc hegniuing dthl.pemdt AIR HANDLING UNIT(OVER 10,000CEM) CONSTRUCTION TAX
Slgmree AB
Signature, r/C�r.n Ext-TAusrErooD av/Duch CONSTRUCTION TAX PAID:
HAZARDOUSMA ERIALSDISCLOSURE
Will thea pbeara on future building part storeor hand le haeardou. - HEATING UNIT(10100,OD0 BTT!)
malcdalas defined by the Cupertlro Munldpal Coda Chapter 9.17,end the Date RCeel t#
Yes
HTe."lt1haMSaletyCm,ler�–,lsv1.=(")? �7s (��7TT� T�nT CLINrr(OVER10O,"EITln TOTAL: 24.50
TVul AeapplloM ar futua WJdingNOT S u.equim'ThfbttMvim VINTILATIONFANNINGLEE=) ISSUANCE DATE
Q�LhbheMt agenneus.bamtsrrdnacab as defined by 1M Bay M<a AU PAID
IxyMamgemenaDLtrldl BORFRODMPOEQ'ORIOQOWBTU) A
Yn ❑No
shave mad the h.rdow rrWedals requirements under Chapter 695 of BOILER-ODMP(OVER 1EUM BTU1 131990 -
theGli!«cab Health h Safety Cod,SMbru 25505,25533.nd 75534.1
Chet v t I cat
undmterd Ct if the building dote.noteurrently have a tenant,that It is my NEW RESIDENTIAL N= 9OFr s
nespomb0lty to notify the«apart d the requirement.which wont be met
Prior t arm da Iflotc parry.
ty, 0f CuOeTtino
cr«ath agent Date ISSUED BY: VGC_
TOTAL
OFFICE COPY