20731 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proed ldemlfkatlw PFRhOT NO.
Building AddmM& ` p, ,
22900 Cristo Rev Drive So' X1.19 SO`V6J i 20731
are aces. - one:
Forum Life Care CITY OF CUPERTINO-BUILDING DIVISION January 2, 1991
• Centrad«.Name: Lc.No: APPLICATION /PERMIT
' Mrn Electric, Inc. 14134 . g(TILDINGPELECTRICA PLUu, INGMF NICAL , CATEGORY• colvrna,.
Amhilrct/Engi.. I I.k.N.
HK16T BUILDING PERMIT INFO
Qn ELECTRIC PERMIT FEE
Addm.535 Mission St. , San Francisco
PERMIT ISSUANCE ev ❑ ® ❑ ElLICENSED CONTRACTORS DECLARATION
I hereby affirm that l am laceneed under provWmu of Chapter 9(mmmm< APPLIANCE-RESIDENTIAL JOB DCSCI2ILTION
ing with Section 7000)of Divituen3 ofthe thued.and ProlnaloraCude,and my
L
im. Cl,ae andL&k!i 386973 PAS Z� Temporary power --
mb contractor 7� south of bldg. 1
ARCHITECTS DECLARATION 20e-1000 ANIPS
q�v cc$z� IuMaatard my plan,Mull be umd n w
public mods. OVER 1000MPS ASQ.FI'.FLOOR AREA _ $/SQ.FE.
ou
k z[j Licensed PMeulorul SIGNS ELECTRICAL
G Qka OWNER-BUILDER DECLARATION SPECIAL C]I2C[JIT/M19C
7HaGG�77 owingyanenntlutism esemptfromth[C ProfeamsCode:Amy cat hs ALE D Iw'
ppYI county n.
tires a permint t
to earmeuMem ardr,impme, Code Amy city or ,v
O Z ti� 7IIAP.MEEFI20R POLE MST.
F wntywhkh requires pemdt tocorutruq alter,lmpmve,demolish,orrtpalr ^ ..
e�Y�s anystmcturt prbrto lb leorave,also rtqulrnthe appBantfawdr permit to POWTUt DEVICES E F{
SNe a signed statement that he b horned pursuant to the pre iabv of the R. ••
a� Contnedori Wceroe l.w(Chapter 9(co.ruing with Section 7000)of D(A. SWIIh NG POOL ELECTRIC
O don3of the Bunlneesand PfOfsbro Code)orthH hebeu thertlromand ' A ATION
l S2 5 the basis for the alleged exemption. Any violation of Section 70315 by any OUTIXTSSWITCHESFIXTURES '
applicant fora permit subjecte the applicant to a dvil penalty of not more than -
M hundred ddlam WOW.
1,aerty
s owner of the prop ,or my employ.with wage,as their aok NEW RESIDENTIAL REM SQFE. STORIES TYPE CONSTRUCTION
z�' compnmtadon,wWdothe worksrad theWudure b out Intended or offered for
sak(Sac-7044,Bualrua aM Prdnebna Cade:The CoMradoe.Wave Law
don one apply to an owner of property who builds or improves themon,and OCC GROUP RES UNTIE
Ea who don such work hlmeef athiaugh hie own emplgeq eprovided thatwIh
Improvernamarerotimenddoroffered farsak.lfhowever,thebulklingor TOTAL a
Impmvement b sold within aneyea rof completion,the owner-huMerwlll have
Ile den of rent"that he dad rot build or improve fee purpose of k.). QTy. PLUMBING PERMIT FEE FLOODMNE AIN
L,J S as owner of the property,am esshuhmly mntncting with 11avM I'FltMITL4IlANCE
mnlradan to emeu ctthe project(Sm 7014,Buslom and Prdesabro Code:
The Contractor's License Law dm net apply to an owner of property who ALTER-DRAIN h VEM-WA7IIt(EA)
Wild.or Improve,thereon, and who centra. fa auch p,jetla with a
c�?dona)Banned pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
L.J I am exempt under Sec B h P C for thio map on
Owner Dab®
DRAINS FLOOK ROOF,AREA,GOND. SANITARY Y_ N_
mrp--Ys; WORKMAN COMPENSATION DEM RA TI ON RECEIPT#FaIURIS PER TRAP SCI1OOL TAX Y_ N_
Rya hereby affirm that I have a arUOoa
cate of consent to sell-lom, a
artiBole of Workers'Comprroat4 Iwrrance ora ceulllN ropy themo(l5ec RIXTIIT a
3�0° 'b�)WP50408194 GASEl5YSA1-1ING40 DES PARK FEE Y_ N_
Co�an�rl YPir1p Tl r�Tt CAS PA.SYSTEM-0VER 4IRA) BUILDING DIVISION IVISIONIT.."
ffertNed copy b hemby(uMe city GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�CedBid ropy b(Bed with the city Inspection division.
CERTIFICATE OF O(EM MON FROM WOR K ERS GREASE TRAP
COMPENSATION A CE
- PAI)
( ctionneednodcornplddffthapermbfororchundddollrsSEWFRSAMTARYSIORM FA 3IDF
Date Reel t#
(510WInlm.)
WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certify mphat bthepeAomunaof themak an as WchthiopermitbIto the
I shag not employ any person In any manner at n b become object to the WATER SYSIFM/TREATING .
Workm'Compenutbnl�wa al C+Ilfornb. Due PAID
A
oP Bunt
Z �
NOTICE TO AIrI'LICANT:R,after making this Certificate o(Exemptbn,you NEW RESIDFNBAL 1rLMB.__SQ}T. Date Revel t#
should bemms subFct to the Workeri Compensa bre peovbbru of the Labor TOTAL:
~ CO Code,you must forthwith comply with such provinbv orthb permit ahallbe
W > deemed revoked. — BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a IhembyaNrm thatthereba cormhuctlonkndlrrgageneyfortheperfon, TOTAL: ELECTRIC FEE
7 Z once of the work lorwNch thio permit b iMemd 03,,3071,CN.C) L_
O Lendre-NaraPLUMBING FEE
LL F Lenders Addre,s QTY. MECHANICAL PERMIT FEE MECHANICAL FEE .
OW lane/ythatlhaverndthbapplfcatbnaM nabthat lheaboveldormulon
1 Iamrrect lag.toccmplyw haBcftyaMmuntyordi. a..duatelaws PERMIT NUANCE FEES PAID:
} N relating to building construction,and hemby authoubte mprtxntativn ofthis -
Z city to enter upon the Ahm,mentloned property for Impectbn purpoea. ALTER OR ADDTO MICH. Date Recti t#
— (We)agree to save,IMemdty an d keep harMeas the City of Cupertino
agalrut liabilities,judgments,coataand eaper.which may manywayaceue AIR HANIILING UNIT(TO 10,000 CFM)- AL:
agoWl�t said City in ao(the gat&IngdW SUBTaTAIR HANDLING UNIT(OVER 10,000CFM) C0NSTRUCI7
\'1e,) I fI(�N T/X'IID:
Sagv olApptrona —CY{e IXHAUSFHOODM'/DUCn CONSTRUC
HAZA �6
AlARDOUS MATE RIALS DISCUDSUR
Willthe .fined by the
ure pbuilding Wdp.1 tode,ChhaMk Z and
the 11EA77NC UNIT(TO 100,17!10 BTL7 - Date R2CC a
matrrlal andAned bytk Cupertino Mu NdpalCde,Chapter 9.1 1,and the , r
Hcahh and Safety Code Section�]5532(a)7 14FATING UNBT(OVER 100,"B"IU)
Lyea t]No It applicable _
l the appllcard or haumbulldingoaupant use equlprrcm ordevlces VENTILATION FAN(SINGLE RESID) 1$$UANCE DATE
which emit handous air contamlnards as deRad by tat Bay Area Air
O Q,ralityyh .,,S'ment Dbtrlct7 IIOII.ER-COMP OHP OR IW,"BTU)
rYn ❑No
I mad thehav dao mtc b glrcmenbunder Cha pterG95 of BO LER-COMP OVER 100,0008
the Gidomla He&th k S.(ety Code,Sedbm 25505,25533 and 25534. I
understand that if the building don not currently have a tenant,that itis my NEW RESIDENTIAL MECH. SQ'rF .
r®pomdbdity to notifythe occupant&the mquiremenb which mem be root
prlatoissuana dace 0cateofO pancy.
I, " c1/J &
Owners authorised igen IT�i�— ISSUED BY:�f._
TOTAL:
OFFICE COPY