20724 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification FORUM SNF 6 PCF PERALT NO.
Building Addm,a: ^O 1") /1 A
22900 Cristo Re Drive G / G 4
Phone
Forum Life Care . CITY OF CUPERTINO-BUILDINGDIVISION September 21, 1990
Conrado .Nan`01 LlcNo: APPLICATION /PERMIT
Viking Electric, Inc. 14134 CATEGORY CONTROL.
Arrhkd/Fngieeer. Lie No:- BUfLDINGF�,ECTRICA4rLUNBINGMECHANICAL
HKIST BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Adds. 535 Mission St. , San Francisc1 rFxARTIssuAFl� 12 O
LICENSED CONTRACTOR'S DECLARATION
I hereby.fftrm that l am beeped under provblons of Chapter 9(cvunm
r1 APPLiANCESRESIDFNLAL B RR'UON
Ingwbh-%dbn7000)ofDM .3ofthe Bu.b .d Profesal.Code,and
ITemporary power for
Ike..I,mmbbY8nal�f, 386973 - PANELSLice..Cla. 2 (12.50 ea.) 25.00
Dat` Conrador SNF. 6 PCF
ARCHITECT'S DECLARATION 201-1000
WQ% I urrerstand my plana shall be used u public record.. OVERIWOAMPS SQ.FT.FLOOR AREA $/SQ.Fr.
• �d [j Lbenacd Pm(essbnal SIGNSELECTRICAL
�5 - OWNER-BUILDER DECLARATION 51'PGIALCR2CUFf/MLSC
t' A I herebyafflrrnthat l am m
exempt frotheCordeactor n
-Limelawforthe
following re .(Semm.70313,Budmem f and Proanion,Code:Any city ar
F� c aa°nntywhkhreqube.aper tommtrud,alter,bnpmve,demalbh,ormWr 1 TEMP.MEITRORPOLE INST. 10.00
Ib a statement athat he b,.Ilbnonurceryd pursuant tothe
no vwLacmha,of the POWER
DEVICES
05 Contractor-Llenaelaw(Chapter9(mmmencingwBhSedbn7taMofD�-
stn 3 of the Business and ProfmaremCede)orthat he b exempt therefromare IVOI.F].ECIIUC VAL ON
the hub for the alleged exemption. Any violation of Section 70315 by any
x.55 05 applicant fora permit wbjorta the applicant to a del penalty of nor more than OITH'E'1'SVCICHFSFUOl1RE5
6 rave hundred dollars( Aq. h-EwR®EMIAL EI.ECTR
�a ❑I,a,owner of the property,or rrry employees with wages an their sole �'r' SIjJRI' TYPE CONSTRUCTION
mmpensaHon,wllldotk work andthe vtncture brmt udended or offered for !
On sat(Ser.70KBu.Ircn.MPmreaal°ntCadyTheCamractor.License Law I laaaawho -
�js$ doesoossucyman owner dplf roxighwow,rtedaoyer,pvntkrmn,and ^ OCGC Q RF5.UNITS
0. impdm eh r;r lm+ededomtgh hLaoun .fi,howeprovdeoildingor, /
Imptovememi aremtithindrd earofcdfmsab.If,havever,thebuiWingm ! / -W '�
impucdmerd proviiasoldg the he ell not Iofld or im nwe for purpose
serwWhive
OK Nmol proving thrtkdd cot baud orlmprove le purpose of axle.). QTY. PLU(v1BING'P RMI
_jI,a.owner of the property,am.exclusWe)y contracting with Iben.ed Fj
FLOOD ZONE APN
mntractom to contract the pmjed(See 7014 Buair.and Imfixebn CadI,: PFRMRI�j.NCE t
Tk Contractor's License Law don no apply to an owner d property who
Wild. or Improves thereae, and who contract, for wch pSokm with a ALTER-DRAINk
o"4adu(.)banned purwant to the Comradoe.Lim.Law. BACK FLAW PROTECT.DEVICEFEE SUMMARY
LJ I am exempt under Sec B k P C for thio resaon
® OUTSIDEFEES
Owner One DRAINS-FLOOR ROOF,AREA,COND. SANRARY Y_ N_
WORIQNAN COMPENSATION DECLARATION BBC=Y
I hereby affirm the I lura a o rHHute a entrant to self-imuce,or a FLCTURFS PER TRAP
enTote St710pL TAK Y_ N_
riflo(Worken'Cwnpewtlon Inuranca ax¢rtl(led mthereof$ec. �
3300,ndeCJ CAS EA,SYSTEM-11NC/OUTLETS PARKF-EE Y_ N_
Talky# WP50408194 - RECEIPT
Coman_s F•• csFA.bYsrFMovIt�(EA)
RCIPT.
m nrFires d BUILDINGDIV
ISION FTFS.
eartined copy b heresy bmw,d
copy CREASE/INDUS RI,WASTE TNTFRC=R PLANCHECK FEE
Certlfled b filed with the Thr inspection dhiNon.
CERTIFICATE OF F;-M FION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SEIVFR-SANEEARY-STORM EA.20*7 Date Recei t#
(TN-.edbn need sat k<ompinN b the Permit b for orc hundml doban
(S]°°)ales`) ENERGY FEE Y. N
]adby the lnthe pedma aM
ouno(thewltforwchthb b boned, ER HEATERned, WHEATERW/VENT/II.ECTR _
I sheb not empty any person in any runner w n m become wbjed to the WATER SYSIIM/TREATING
Worltcrs'Compensation law-of Callfamla. Date PAID
ZO Z NOTICEApplIcanTO NEW RESIDENTIAL 1gMB. SQ.Fr. Date Recei t#
O enoxild NOTICEcome subject to
after making rs'Comhb Certificate of Exemption,yw
ccN Code,yecome.urthwit the Work en'CompentrtbnprovbbwoftheTabbe TOTAL:
or
_ Code,yr coked.forthwith romply with such provlabru orthl-permX")I be� > decmN revolted. '
(L O CONSTRUCTION LFTDING AGENCY SE IC FEE
BUILDING FEE
a lhereby./Orm that there b a construction lending agency for the pedorm TOTAL: ELECT-RIC FEE 7
7 Z .naafthoworltmmd
rwhkhthbpetlal� C&r 3osi,Clv.c)
(� O Iardrr.N.me PLUMBING FEE
LL H I<minrs Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I mKifythat l ave read thlaappllratbnand stmethn the above FfmcnaHan
a bmned.fxgre Wco plywnhaudtyandmuntyoNman ea do telawa PERMIT mvANCE FEES PAID. 1
>. crating to bullding conatmctbn,and hereby autharta reprwmativn of thio
F = cry to enter u Pon the 11 o mentioned Property for bupectbn par rposea. ALTFRORADDTOMFGH.
(We)agree to save,indemnify an d ltccp harmleaa the City of Cupertlw Date Recelpt#
ageumb.bblHe.,NdgmeMe,avws.M ezpeneea which m.yln anywayamue AIRRANDLTNG UNIT UO ID,WOCFM)
d Chyles ena of thegr, of thi porrnt. SUBTOTAL:
AIR IiANDLING UNIT(OVER IO,WOCFM) CONSTRUCTION TAX
Rgvnreof Apca Contrador Mix, IXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
RDOUS MATERIALSOZSCLUSURE
WBitheappllcantmfut-rebullding.panto°reorhaMlehur s HFATINGUNIT(10100,0DORM Date ReCei f#
material as defined by the Cupertino Municipal Code,Chapter 9.l;and the
Health and Safety Cade�+—S�ection 2S532p)3 HEATING UNIT(OVER 100,000 BM TOTAL: 47.00
qY. . IJ No Not applicable
UItheapplicatdm turebuildbR.p.nt usecquipment adevkn VENTILATION FAN(SINGLE RESID) ISSLJ4� Fi.DATE
which emit h.vrdous air mnt.mlruM.a,dared by the Bay Area Air 1+�6/
Quality Management DWrkt7 BORER-COMP Orli'OR 100,000 BTU)
Yes n❑Na 1990
haw.resat,rbavrd L4yCWeS.b .25505ta°narrcmpN. I of Bo1LER-marcmvFTelro,oroRnn ,SEP 21
the Callfamla Heath k i fidin cine,Srdmnotly lb 73333 aaa 73531. 1
urdrrsUMtktn notihe fy
the
of t the
mnts tenant at It mot h'EW RESIDENTIAL A1E41. SQ.Fr.
rvpon(bWtyto ndBy the occvpara al the requlrcrrcnb which mnekmet
prior to as Cert(fla of for .my. CI 0(GO 1111M
OwmiAx au1horiud ent Date TOTAL ISSUED BY. -
OFFICE COPY