20732 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY i
Building Prn M Identification PELWTNO_
a BuIldingAddress: Sto Rey Drive � 1"� Vef " ' 20732
Forum Life Care one. _ CITY OC CUPERTINO-BUILDINGDIVISION January 2, 1991
contractee Name: for.No: APPLICATION I PERMIT
Electric, Tnr lZI114 BUnLI ELBCnUCAL-PLUMBINGMC NlCAL CATEGORY CONTROL
A Meet/ neer. IY No:
HKI6T QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add— 535 Mission St. , San Francisco PEKhIlTISSUANCE
LICENSED CONTRACTOR'S DECLARATION El U 0 El
I hereby
afflrmthatlam llcmaed urderptwfeloruafChapter9(commune AI'feI.IAIJCLSRFSBJENTIAL JOB D99CRUIMN
Ingwlth Sectbn700010/DlvWon3afthe BusitrvandlhofestlauOxds,and
Bcenae b m full force and efert. PANELS Temporary power --
Licenseclan,&LO—L is 1386973
Dae cmtactm up To 2ailAixfPs near Villa X -
ARCHITECPS DECLARATION I- AMPS
X'Z I understand my plana sha0 be used as ER public records. OV1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
Licrosed]idemioral SIGNS ELECTRICAL
OWNERBUILDER DECLARATION SITCIAL CIRCUIT/MLSC
Ihertby a(Onn that lamexemptfromtW Comr Coro lJcxrue l�wfor the
P.
folbwing reason.f5ectlmi MIS,Boemessand PmI.Jc.Code:Anycttyor
O P. TCMP.METEt OR POLE INj�igmg
S
C4C� muntywhkh rryulroapermkrocorutruct,tlter,lmptwe,demolbh,orrepalr
�C'',SS,,�� anysmmmpr wluL arceaborequlrntheappllantfmouchpemdtto DEVICES
� -fi- �_
rt 0 Ole a signed statement that he Is licensed pursuant to the provisions of the ON
Ou, Contractor's license law(Chapter9(commencingwhhSectbn70MofDfvl-
g�05 afon 3ofthe Business and Prdubes Code)orthe he beaempt theefromard SWAIMINGIGOL EIECTRI LUATION
the Web for the alleged exemption. My Wdation o/Se tion 70715 by my
a pp0cantforagerm bjenetheappllcanttoad ipemkyofnat=m(e n O=TS-SWITCHF--,FEKTURES ATE
fi me hundred ddwa(SM.
I,as owner of the NEWRF�EJMLEDUR SO Fr SfOW6 TYPE CONSTRUCTION
�n property,or my employees of with wded r their door
mmporoatlKBual .wok fesalond ;Code:
brat Intended oreffareseLaw -
a Rd for
pt dole(scat ,ply to anowstd Professions Cod e:The Contractors therms Lw
$ dm scat.,plytock owns of property wholou mparlmpravn thereon.and OCC.CROUI' RLS.UIJTTS
C• who donsuchworkhimself or through hbown emplgces,Pmvided that such
ImpmvemWs are cot bteaded oroffered fmuLe.IL hmvever,thebuilding m TOTAL: 10
impxwerne d beold within oneyearo/completion,the Owner-lou Merw0l have
b co
t en of proving the he did t bu0d or improve for purpose of sale.). QTY. PLUM13INGPERMIT FEE
-i1,ate owner of tW property,am exchWvely contracting with licensed FLOOD ZDNE AYN
contractor to construct the proFct(See 70K Buenew and Pmfi.b.Cod,. EMIT L%7J'ANCE
The Canrsctor.Liccrue Law does not apply to an owner a property who ALTER DRAIN 6 VENT-WATER TA)
builds or Improvthereort and who contracts for such p(ajects with a FEE SUMMARY
ofittIcmrWlicensed pursuant to the Contractor's Licenae law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B 4 P C for this reason
Ovner Dae
DRAINS nODIi ROOF,AREA,COND. SANITARY Y N
WORKMAN COMPENSATION DECLARATION RECEI T I
hereby form that l love•certiflate of consent to self-Inane,m a �'S'PER TRAP SCI{OOL TAA Y_ N_
ordiflate of Y✓ohen'Compevatlon Insurance or a cenufied copy thereof iSec. RFfFJ1T I
MOO,Lab ) ,40 GAS EA.SYSTEM-t INCL OUILEPS PARK FEE Y_ N
Cam I CAS FA.SYSIFAfOVERI(EA) RECEBTe
IF eman C Fshe BUILDLIGDMSION FEES
CMNed copy b heat with Us,cit. -- GREASE/INDusrRL WASTE INTERCEPTOR PLANCHECK FEE
Cartlfled mpy b filed with the Gy IropeGlon dldalon. '
CERTIFICATE OF F](c PTION FROM WORKERS GREASE LRM PAID
COMPENSATIONuINSURANCE SEIYF.R-SANTTARY-SFORM EA 2DTT Date Repel tit
(fhla aertbn need eat 4 conicomple4d Bthe pemdt b furore hundred do0an
(f100)alessJ wATERHEATERW/VENT/ELEGIx ENERGYFEE Y N
Icertlfy that iothe penfamance of thewak(orwhlch WspemdtbbsueQ
I Out]not employ any percmr In any manner n as to become subject to the WATER SYSTEM/TREAT NG
wmkcriCompensatbnlawaefCawomb. Data PAID
NEWRFSIDFNDALPLMB. SQFE
Applicant
_Z ZO NOTICE TOAPPLICANT.tate .ri oakingthb atue ateofuou.ft ion,you Dale Reoei tit
ahwld humus subject it the Workers'Coupematkn provbbro of the Labor W~ TOTAL to dermad urrvsa(orthwhh comply with ouch pevvbbroorthb permit shillW deemed rooked.
BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
O. O Thereby affirm,
.rkfthatthanebae construction lending ,Ci for Ilse perform
7 Z anm dthe work(or whkh thio perMtleLwed LSee 309'7,Clv.C.) TOTAL: ELECTRIC FEE
V O Lender'.Name PLUMBING FEE
IL F Lerner.Addnea. QTY. MECHANICAL PERMIT FEE MECHAMCAL FEE `
OW 1certlfythe l have read thbappllatbn and statethal theexwo information
1 Is cormct.I agree to comply whh all city and county ordbanor and state laws PERMIT ISSUANCE FEES PAID:
r N relating to building corotmctlon,and hertbyetthoAu mpresetntattvn of this
H Z city Roeser,upon the above-mentioned property for Inspection purposes. ALTER OR ADDTD MECH. Date Revel tq
_ (Wel agree to save,hulamnfy an d keep harmless the City of Cupertino AIR HANDLING UNIT CFM)
agerst BabNtim,Odgmenb.00.tsard experses hkh mayln anywayaccrue (TO 10,000 SUBTOTAL:
.got. dCltyln;q�� fthsgraningdthbpermlt.
W'd XI i IbAI AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of pp ant mtractor Date EXHAUSTHOODM/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheapplican orfnturtbulldingoccupantstomorWMk ha:arduus HEATING UNIT(TO 100,000 MM .Date Recei IN
material as defIrud by the Cupertino Municipal Cade,CWptcr 9.1 Z and the
11eahh and Safety Cade�Lu-�S�ection 25531(a)r p HEATING UNIT(OVER 100,OW BTU) TOTAL:
❑W ItheYes � Ilan or turebuildoons pct\xieab lie devirm VFNITLATION FAN RINGLE RESID)
PP 8 N nit P ISSUANPI }�E�'
which enft
. oavair contaminants as defined!defined!bytW Bay Arta Air Qua ILLYMnmgcmert ement Dlstrrict?No BODER-COMP aEMP OR 100,000 BTU) �
YesFF��No
( Wve read the harardcus meteriele requberrcnb under Chapter 6.95 of BOILER-COMP(OVER t00,0ID BTU)
the Callforma Health Lc SafetyCode,SMbns 75505,ZM3 and 2S53C. I
urdastand that lfthe buildingdoes not currently have atenant,that It is my NEW RESIDENTIAL hfECH. SQ.FT. ��....
rmortoisuato ndlfy theoate.f dtherequlrenrmewhich rtuetW met lAeai aL',
prtm�bmanceda rtllkate af0¢vpanry.
it
10
1144
Ownerm authorlsda eht0 - ISSl1EDB ���W` -
j
OFFICE COPY