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04090086
0� z CITY OF CUPERTINO `" "" " ''"' ;'` '' `f6....... rg BUILDING DIVISIONPERMIT k CONTRACT,0RANF©RMATION�.,i.., BUILDING ADDRESS: DEVCON CONSTRUCTION INC PERMIT"04090086 ERS NAME: PERMn ISSUE DATE THE PHONE: PHONE: SANITARY 0. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby affirm that 1 nn licensed under provisions of Chapter 9 (commencing with section 7") of Division 3.f she Box. surd Professions Code. and my license is infull lnle a ardcrcea License Cla Lie. a REVISION --SANITARY PLAN—05 Date Contractor NO NEW PERMIT ISSUED ORIG. #04050120 ARCHITECTS DECLARATION 1 understand my plans fisull he used as public meads Licensed Professional OWNER -BUILDER DECLARATION ' I hereby affirm that 1 am exempt from the CPntracwr'e License law for tW following moon. (Section 7031.5. Business and Professions Code: Any city or county which motions is .it to construct, eller, improve, demolish, or repair any euunure prior m its issuance. also requires the applicant for such permit to file a signed statement Sq. FL Floor Area Valuation$41 that he is licensed pursuant o the provisions of the Commnor's License Law (Chapter 9 mmmmencing with Section'IWO) of Division 3 of IW Business and Professions Code) or that he of exempt thuefrom and the Imus fm dx alleged exemption. Any violation of APN Number Occupancy Type Sudor 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of not more than fin hundred dollars (SXap. 34254016.00 I, u ownu of the pmp ny, m my employes with wagu is their sole emmpensation, Required Inspections will do the work, and On swcmre is not intended oroffered for sale (Sec. 1064, Business and Professions Code: The Contractors License law does not apply to an owner of property who builds orimprnvu thereon. and who doessuch work himself or through his Own employ=, provided thatsuch improvements and, not intended oro0ered for sale. If, however. the building or improvement is sold within one year of completion, the owner - W ilder will have she burden of proving Nat he did not build or improve for purpose of e� seek.). �1 Fasm.)as owner of the property, am exclusively connecting with licensed contmctom to niwct the project (See. 70al Business and Pmfusiom Code:) The Connector's Li. cmc law docs not apply to an owner of property who builds or improves daemon, and who contracts for such pmjccts with a contractor(s) licensed pursuant o One Contmdar's License Law. ❑ 1 am exempt under Sm. B A P C for this mason C�..-.N Dam q-15'�i WORKER'S CO ECLARATION -I hereby affirm under penalty of perjury one of me follmaviO&Ccurations: I have and will maintain a Ccrifirure o(Consent to colt -insure for WorkeriCompen- Citinn, o provided for by Section 3100 of Ne Labor Code, for the perfismonoe of use work for which this permit is issued. 0 1 have arm will maintain Wmker's Cmmpsmarim r Insurance, as required by Section 3100of the Labor Code. for the performance of the work for which this permit is issued. My Worker's Compensation Insurance Cartier and Policy number art: Carrier: Policy Nm.: CERTIFICATE OF EXEM MON FROM WORKERS' COMPENSATION INSURANCE (Thu scedha need not W completed if the permit is forms. hundred dollars ($10() or Ices.) I anify Out in On perfn.... of the work for which Nis pcomi, or issued. I shall nm employ any person in any mannerm az to become subject to the Workeri Compenssuon Laws of Carboni., Date Applicant NOTICE TO APPLICANT: IL after making this Ceniecare of Exemption, you should became subject to the Worker's Compensation provisions of she labor Code, you must forthwith comply with such provisions or this permit shall W doomed revoked. Out ft.UCTIONLENDINGAGENCY 1 hereby thi Out mere is 30 lending agency for tM perfurtnar¢c of which s ed (See. ' Or work for which mu permit is issued (Sec. 7097. Civ. C.) Lender's None L Lender's Address j 1 ttnify Nat I have read Nis application and sum Our the above infmmun.. is ' cmnect I agree to comply with all city and county eminences and sum laws relating m building construction. and hereby aumorine Mpresemnives of mise city to enter upon the shove-menumn.d property for inspection purposes (We) agme to save, indemnify and keep harmless Om City of Cupertino against j liabiliues,judgments,costs and,spic. which may in any way sccom against said City p 7 to consequence of the gmmit. nung of this per ' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT 1/ Issued by: Da SOURCE RfGUyApQ�lS. l -) I-fs °µ Re -roofs Type of Roof SOX; Um of ApplinardConuector Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building Occupant tore or handle hasardous material defined by the Cupertino Municipal Code, Chapter 9, 11, and the Health and Safety C. Section 25532(.)1 ❑Yes ANo All roofs shall be inspected prior [o any roofing mat ial being installed. If a roof is installed without first obtaining an inspe ion, I agree to remove Will thea scant or future Wadin occupant age equipment or devices which pp 6 P yuipr Qu emit harardoux air contaminants az JcfincJ by the Bay Arca Air Quality Management all new materials for inspection. Dunict? ❑Yes �mN 1 have mad me haaamous mao:rials.,Orem... under Chapter 6.95 CFO. Califma. ria Heal m & Safcry Code, Sections 25505,25533 and 25534.1 understand Out if me Wilding does not currently have a ¢nam out it is my responsibility to nouly the mmeupart of the regmmmenu which must h m Her to issuance of a Ccmncate of Ocaoey. Signature of Applicant Date T a i-04 All roof coverings to be Class "B" or better Owner or authorised COOV Date Date Ja Op zv, -c Yt- no ya;a 1U L6S zois rZ w�C CITY OF CUPERTINO`�-` i O y < $ _ 'Z Q QLender's Z Q F-' U W 6. N Z CONTRAGTOR`INFORMWN BUILDING DIVISION PERN� H BUILDID'G ADDR17SS: DEVCON CONSTRUCTION INC PE"""04090086 OWNER'S NAME: PERMIT LSSUE DATE THE FORUM )NE: (408)949-8200 SANITARY 0, CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description 1 hcrchy affirm that I am licensed under provisions of Chapter 9 (commencing p with Section 'AXK)) mf Division 3 of fee Businexs and Pfufessiunx Code, and my license is in full force imm�eClass erre"' REVISION --SANITARY PLAN—05 Class Lic. N Dale Contractor NO NEW PERMIT ISSUED ORIG. #04050120 ARCHITECTS DECLARATION 1 understand my plans shall W used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for the following reason. (Section 7030.5. Business and Professions Code: Anycity or county which squires a permit m construct, alter, improve, demolish, or repair any stmcwte prior m its issuance. also requires the applicant for such Permit rile a signed statement that he is licensed putaxito(he provisions OfOnComraaofiLi¢nuLaw (Chapter 9 Sq. Ft. Floor Area Valuation$41 (commencing with Section 7") of Division of the Business and Professions Code) or Nat he is exempt therefrom and the basis for the alleged exemption. Any violation of APN Number Occupancy Type Section 7031.5 by any applicant for a permit subjemthe applicant to a civil penalty Of not mare than five hundred ddlo s (SSW). 34254016.00 01, as owner of the propery. m my employes with wage, u their sole compensation, Required Inspections will do the work. and the structure is not intended or offered for sale (SeeS054, Business and Prreasions Code: The Contractors License Law dors not apply to an owner of property who builds orimprovcs thereon, and who does such work himselfor through his own employees, provided that such improvements are not intended or oRered for sale. II. however, the building or improvement is sold within one year of completion, the owner. cpt builder will have the burden of proving Nat he did not build or improve for purpose of o �e�.). i- I re owsmf of the pfopsny am coclusivdy contracting with licensed Contractors to -A eonswa the project (Sec. toBol. Business and The Conuemon. n, who ds or and entire law docs not apply to owner of property who builds m impf0ws thcsrac and \ for such projects with a conte<loKs) licensed Pursuant to the Convenor's who contracts c m y` Lact License Law. V ❑lam exempt under Sec recon �.B&PCfnnhis Owner s-.n.•w-� `_Date �(SKfi WORKER'S COM ENSATI DECLARATION 1 M1ereby rf0sm under penalty of perjury or¢ of Ne followingkedarations: - I have and of Section Cod insure fen Workers Compere / �� r... smirk, as 37W of the Tabor code, for the performance of the providedby the Labor chi for by Senium / G� � d. work for which this permit is issued. which ❑ I have and will maintain Worker's Compensation Instance, as required by Section V /� 3700of the labor Code. for the performance of Ne work for which thispermitisissued. My Worker's Compensation Insuan¢ Cartier and Policy number ase: Cartier: Policy No.: _ CERTIFICATE OF EX EM MON FROM WORKERS' COMPENSATION INSURANCE (Ibis section mend not W completed if the permit is for one hundred dollars (51(X1) _ or Icss) I certify that in the performanm of to work for which this Permit is issued. I shall not employ any person in any manner am as m become subject the Workefs' Compensation Laws of California. Date Applicant NOTICE TO APPLICANT: If, after making this Ceniliege of Exemption, you should become subject to the Worker's Compensation provisions of the labor Code, you must forthwith comply with such pmvlslons or his permit shall W deemed revoked. CONSTRUCTION LENDING AGENCY ' Ino the performance of 1 hereby affirm Natmereissed See. 3W7. Co, Ne work fur which this permit is issued (Sec. ]099. CivCJ Name Isnaera Aaare:: I ¢miry that 1 have read this application and sum Nat me show information is ' correct. 1 agree m comply wife all city and county eminences and sole laws relating to building construction, and hereby andante spreumatives of tins city to enter upon the above-mentioned property for ins to ion purposes. (We) agree m save, mahouni fy and keep harmless the City of Cupertino against liabilities.jul,men¢, cost andex,mccs which may in any way were against sold City /• mconsequence ofthe gLIanhngOfthisPermit. I / APPCANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issuedb y; Da SOURCERSGU ATll Np. t 5 f Re -roofs Type of Roof rc PplioanDate Sig amof A or Date HAZARDOUS MATE RIALS DISCLOSURE HAZARDOUS Will the applicant nr (Muni building occupantstorem anndle Heamuusmaterial as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, s�Y� 2ss3z(ar+No All roofs shall be inspected prior to any roofing ma[ ial being installed. If a roof is installed without first obtaining an inspe ion, I agree to remove Will the aPPlicantor, fumy building ..,.Or esu cyuipmem or devices which Iran hazamnus air contaminant M defined by the Bay Arca Air Quality Management all new materials for inspection. District? ❑Yes rrgN I hate real One harardousmzterixls requirements under Chapter 6.95 of the Califm- nisHealth MSafctyCodc.Scions 25505,25533 and 25534, imak nand thmifine Wilding Jona not control, hole a tenant mat it is my responsibility to notify fec seaport of the requirements which ��be mete Qdorw issuance Certificate of OccupancyG Signature of Applicant Dale i a �/� 'V i" l / Cb All roof coverings to be Class "B" or better Owner at authmixcd agent Dam 0 City of Cupertino, 1 - Plan Check Transmittal • Permit# Project Address Owner 04090086 Control# Plancheck# 1 FileDate 9/15/2004 REVISION 23500 CRISTO REY DRIVE FORUM AT RANCHO SA Description REVISED SANITARY Plan Check Status (attach comments and return to Building with pian set) Dept Plan check# J Date Due Date Staff Comment Date Approval? Building 1 9/15/2004 9/29/2004 POH 9/15/2004 Sanitary 1 19/15/200419/29/2004 Additional Plan Check Fee Q Hours Planning Fees Housing Mitigation Fee Amount Heart of the City 9/15/2004 Specific Plan Fee Amount 0 • • DISTRICT MANAGER -ENGINEER MARK THOMAS & COMPANY, INC. DAVID E. ROSS DISTRICT COUNSEL ATKINSON • FARASYN, LLP HAROLD S. TOPPEL September 13, 2004 • 4�~`�p SPNITgq�,o r • s v � � F 20833 STEVENS CREEK BOULEVARD, SUITE 104 CUPERTINO, CALIFORNIA 950142154 (408)2537071 PHONE 0 (408)25}5173 FAX Mr. Alex Johnson MATRIXCM 20370 Town Center Lane, Suite 137 Cupertino, CA 95014 Subject: Sanitary Sewer Connection- The Forum at Rancho San Antonio Name: Healthcare Center Expansion APN: 342-54-016 Dear Mr. Johnson: BOARD OF DIRECTORS WILLIAM A. BOSWORTH DR. JOSEPH F. BROWN JOHN M. GATTO CURTIS B. HARRISON WENDELL H. KERR, JR. The Cupertino Sanitary District has reviewed your submittal, requesting to connect to the existing 6" sanitary sewer lateral on-site for the subject project. We only require that the point of connection be video inspected prior to passing The City of Cupertino Final Inspection. Owner to call District 48 hours prior to video inspection to schedule a District Inspection. If you have any questions or need additional information, please contact Hayde Pacheco or Carl Beckham at 408-253-7863. Thank you for your cooperation. Sincerely yours, MARK THOMAS & COMPANY, INC. District Manager -Engineer David E. Ross • CHB:HJP cc: Poh Yee, City of Cupertino -Building Department SUPPLYING SANITARY SEWERAGE Swim FOR: CITY OF CUPERTINO, PORTIONS OF THE CITIES OF SARATOGA, SUNNYVALE, LOS ALTOS AND SURROUNDING UNINCORPORATED AREAS www. rupertinosonitar ydistrio. rom Is .90 1 /� 19.89 NV INV AD TG 350.94 INV 348.9E JV 349.66 E CRISTO REY DRIVE -------------- - g $$ �II tSDD PIV / ILL�_�� 6' S$CO AD INV345.99 0 30' 40'� TG 351.8 AD . O INV 349.2 TG 354.0 ) INV 348.90 / 6" ssco i RIM 351.60 6" SS INV 348.36 AG ' " TG 3524 INV 349.08,_ A TG 3! INV 349.22 DOMESTIC WATER TG 351.30 FIRE WATER INV 349.42 E PROPOSED BUILDING CONNECT TO ADDITION BLDG ROOF TI a DRAIN (TYP) AD M IP TG 351.2 FF 352.0 INV 349. PAD 350.6 TG 351.30 INV 349.8% DOWN SPOUT CONN. (TYPJ e --'tV�L E SD4H INV 348.2 INV 59.6--� INV IN 354.91 (IX 6" S) _- INVJ \ INV IN 354.21 (E% B" NE) 4' SS P.O.C. \ INV IN 347.09 (E% 36" W) m INV 346.75 V INV OUT 345.29 (E% 36" N) S' HYDRANT I �nzw'o 551.60 TG 351. )w 342,SS SDJ INV 348.0 \\ RIM 3co (/' INV 47AD TS 351„20 INV 349.34 (:,; . TG IN% TG 351.30 NV INV 348.2 INV INV 348.18 _- INVJ i 55 �V I 4' SS P.O.C. e• m INV 346.75 S' HYDRANT I �nzw'o 551.60 TG 351. )w 342,SS SDJ INV 348.0 \\ RIM 3co (/' INV 47AD TS 351„20 INV 349.34 (:,; . TG IN% 349.65 347.74 \ TG 351.20 0 `VO G. \ INV 348.19 $6Gp I j INV 349.70 RIM 351.5 TG 351.30 INV 3423b / o INV 349.80 396,1 5-8D AD 346.35 I\ TG 351.20 TG 351: INV 349.48SDJB 1OPoM 351.45 AD INV 349 \ ( \ (y• INV 345.03 351.22 • im -b q NV INV _- INVJ �V I m FIRE HYDRANT I �nzw'o 551.60 547.48 {52.20 347.38 \ 3co (/' im -b q *ITY OF CUPERTINOO d C/tea / ® CUCITY TYOF O PERMIT APPLICATION FORM �� q o o E6 APN # �j Q Fee Description Date: / Other Appliances MECHANICAL Building Address:f Address: Mailing Address (if different from building address): 23500 Cr; i� ReJ Owner's Name: MECHANICAL Phone #: `THC F-,�' A- RANCMG 54 Fl lo�,v BBOILER4 Contractor: MECHANICAL License #: 1 I.J;JCO.� Com �r��-F.`•�1 -1-�C. MECHANICAL BCONSTAX Contact: Phone: H0g-99z-Szw Cupertino Business License#: A,.+oq Fax: BUILDING BCONSTAXBQ Building Permit Info: BUILDING 'Bldg ® Elect ❑ Plumb ❑ Mech ❑ Job Description: BCONSTAXR Constax - Resi/Mobile R / Commmner Sq.Ft. Floor Area: ' $/bq.rt.: Cost of Project: BELEC200 Occupancy Group: Type of Construction: BENERGY Please check this box if the project is a BUILDING BENERGYADD second -story addition: ❑ ro•ect Size: Standard ❑ Laze ❑ Major ❑ Rays; --,Ie, &KAry Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax - Resi/Mobile BUILDING BELEC1000 Elec 600V <= 1000A ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING C 1 of // Q� CITY Of CUPERTINO r L i &ITY OF CUPERTINO* PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMIvIE New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTME Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pb1g Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING _ f BPREPIPE Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinkler/Backflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain & Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit > 10,000 c8n MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREM13USWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Fumace MECHANICAL BREMFURNOV Relo Furnace > l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non -Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc t1, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL r U 2 of 3 ,cr, agv�mx&, CITY OF CUPERTINO CITY OF CUPERTIN(* PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Sips Add Branch ELECTRICAL BREMSIGNS Remodel Sips, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Inspection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING • 3 of 3