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3618 C.1'1'Y 01' CUPEIMNO LNSPI;CTIOL' RECORD (Office Copy) — LFT 361P _ _ 10625 N. De Anza Blvd ' PEPIIIT N0. SANITARY DIST. NO. LOT 110. ADDRESS ---- Install Tank llr. Ario PROJECT OWNER JOB SITE PHONE NO. PERMIT ISSUED Date ELECTRICAL Building _ Date insp. Electrical Power Pule _ LumhinS Underground ifechanical P.ou€;h Niring Temp. Cas/Fleet. 1Ia.1Ls _ Solar Ceiling Fire S rinkler Fixtures Int/Ext Si ,n ilotors Grounding Misc. Temp. Power _ Other FINAL INSPECTIONS Not Approved _ Date Insp. s PLUMBING Electric Date Insp. Plumbing Backflow !lechanical Underground Solar Underfloor Pool Partial. Rough • Grading Rough Complete I'Lanninp Solar Rough _ Fire Dept. MIM q5 A a ilater & Insulation Health Dept. 17Main Drain DUildinp R/of/S Drain _ Other Gas Other BUILDING Not Approved Date Insp. Pad Certification 11ECHANICAL Foundation Date Insp. Pre-Gunite Underfloor S.M. Slab-1(embrane Ducts & Insulation Bond Beam Fire Dampers Underfloor Girders Fireplace Floor Steel Crease Duct & Hood Tiedowns One Hour Shaft D.iaphrams Condensate Drain Seismic Bracing Equipment Anchorage 11al..Is-Panels Flues & Comb. Air Frame Other Lath Not Approved Wallboards Int/Ext. Firewalls Other Not Approved BUILDING ELECTRICAL PLUMBING IIECHANICAL MISCELLANEOUS APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 1� e BUILDING PROJECT IDENTIFICATION ERMIT NUMBER APPLICATION & PERMITS. 3618 � euuo/cost qJ ' /� u u Aoon/s�G /r. 7 VV ,.,sbld a/A ,2,4 _ BUILDING -ELECTRICAL-PLUMBING-MECHANICAL OWNE W$ - -- � - -f _ LAN CHECK VALIDATION "AM PHONE QTY. ELECTRIC PERMIT FEE ' G CONTRACTOR'S . 3 /Gs�s N E UTLETS-SWITCHES-RECEP 5.00/1.00 A C c f{ Pe/.,,O fella' ND LIGHTING FIXTURES 5.00/1.00 roNTRACTOR's Q APPLIANCES-RES inIDENTIAL 4.00 AOOREss //�/,.,� y J p 3J .!/ ce FHONEgYz$aPb PANELS 5.00 DATE OF APPLICATION onnLHITECT SIGNS 6.00 PLAN CHECK FEE P.L.NO. ENGINEER ^ __LIC.NO. SIGNS TRANS. 3.00 ADDRESS END SPECIAL CIRCUIT 5.00 PERMIT VALIDATION zip TEMP.METER OR POLE INS. 15.00 APPLI rs ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 10.00 ' o o LICENSED CONTRACTORS DECLARATION a i w 1 hereby affirm ille,I ara licensed under provisions of Chapter 9 ISSUANCE DATE (commencing colt coon 7000)of Don 3 of the Business and RLOG. ELECT. PLG. MECH. i Professions Code, my license is in full fa/l0� c El 1:1 E] ❑Z 0 2 License ss L., Number_? ' 0 F Dal Contractor , ¢ m s BUILDING PERMIT Fac i OWNIiR-BUILDER DF.CLARA I INFORMATION wy I hereby e0irm that 1 am exempt from the Contractor s License MISC.- REFER TO ORD F LL o J Law for the following reason.(Sec.7031.5,Busiuessand Professions PERMIT ISSUANCE 6.00 SIFT. % mCode:Any city or county which requires it permit to construct,alter, h ¢ to <G improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. - LIC.NO. - ELEC. 0 LL requires the applicant for such permit to file asigned statement ThalTOTAL TSERWILrUD a w m he is licensed pursuant to the provisions of the Contractor's License ,s Law(Chapter 9(commencing with Section 7000)ofDivision 3 oflhe J GG T.�.v I� z o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE ¢ I- the basis for the alleged exemption.Any violation of Section 7031.5 1 IIRJYPE CONSTR. a3 - by any applicant For is permit subjects the applicant too civil penalty ALTER-DRAIN -WATER (EA.) 4.00 of not more than five hundred dollars IS5001.1: O h as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 oce.GROUP RES.UNITS sole compensation,will do the work,and the structure is not intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who dues such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE himself re through his own employees,provided that such improve- memsarenorintendedornemploees,Pe.ILhawevesche building GAS-EA.SVSTEM.-11NC.40UTLETS 0,00 or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 7,00 BUILDING USE builder will have the burden of proving that he did not build or an. RES IND CON PB Omer Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑ ' licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO. and Professions Code:The Contractor's License Law docs not apply to an owner of feroperty'who builds or improves Ihercon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts for such projects with it contractorls)licensed pursuant to the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO. ❑ I am exempt under Sec.-,B&P.C.I'or this y,/ATER HEATER W/VENT 4.00 _ reason Date Owner WATER SYSTEM 4.00 ACC.DATEACC.FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 1 hereby affirm Ilmi I have a certificate of consent to self-insure, or a certificate of Workers'Compensation Insurance,or a certified ZONING ENO.SITE NO. ropy thereof(Sec.3800 Luh C.1. Policy No. Company-�L.TN 14 O ❑ Certified copy is It inch fur shed FIRE SPRINK ENERGY T-24 z Z ❑ Cerlifiedig y is�f�pd lh pre city inspection division. p Pp cam 11 „/F• / MISC.- REFER TO ORD.Ud v ❑ N❑ v ❑ N❑ H ,� PERMITISSUANCE6.00 FLOOOZONE A.L.U.C. CrLU J CIiRT1E1CCOlIPE EXEMPTION FROM WORKIiRS' - LU COh1PENSATION INSURANCE PLG.CONTR, LIC.N0. PLG. CL O (This section need not be completed if the permit is for one TOTAL Y El NF Y❑ N❑ D Z hundred dollars(S 100)or less.) U O 1 certify that in the'performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY JL H mit is issued, I shall not employ any person in any manner to as m U become subject to the Workers'Compensation Laws of California. w Date Applicant BUILDING ..5� a ALTER OR ADD TO MECH. 4.00 } N NOTICE TO APPLICANT'. If,after making oris Ts'Coicne sa Ex- - f- Z em vision you should become subject to the Wothwit Compensation APPLIANCE 4.00 PLAN CHECK 6� such pons io the Labor Cit shall you must d revoke comply with - 'FEE Q U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10,0004F.M.) 3.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000GEM.) 5.00 SEISMIC FEE .S-1D I hereby affirm that there is a construction lending agency for EXHAUST HOOD IW ITH DUCT) 2.00 the 3097.Civ .0 ante of the work for which this permit is issued(Sec. MICROFILM HEATING UNIT(TO 100,000 B.T.U.) 4.00 Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 Lender's Address ELECTRIC I certify that I have read this dpplictoon a0d sWIC that the ahnve VENTILATION FAN (SINGLE) 3.00 Information is correct 1 agree to comply with all city and county - PLUMBING ordinances and slate Maws relating to building construction, and BOILER-COMP I3 H.P.or 100,000 B.T.U.1 4.00 hereby authorize representatives of this city to enter upon tiro BOILER-COMP IOver.t00,000 BTU)SEE FEE SCH. MECHANICAL above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against hablhl s,judgments, costs and expenses which CONST.TAX may in any Sec, ago nsI said City in consequence.of the PERMIT ISSUANCE 3.00 gr nyM 11 s en tit /} MECH.CONT. LIG NO. MECH. �� /� TOTAL TOTAL /0,3 �3 Signature of Applicant/Contractor l Yate 1 OFFICE COPY - APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTI-FICATION PERMIT NUMBER BU LDMG ` APPLICATION & PERMIT 4 3 ADDRESS / ^ �^� - 1• Vr n�� /V1 L N hI BUILDING -ELECTRICAL-PLUMBING-MECHANICAL OWNER'S PLAN CHECK VALIDATION NAME (] QTY. ELECTRIC PERMIT FEE �J AC C 5 PHONE NANTRACTORs UTLETS-SWITCHES-RECEP 5.00/1.00 NAME R _E EtEGTRlG NO, 299ffl I.C.No. LIGHTING FIXTURES 5.00/1.00 CONTRACTOR'S ADDRESS ��/00 eEM-12 AV'?4 APPLIANCES ES-RESIDENTIAL 4.00 • .9.1�o zo PHONE g47•Z7•'77 PANELS S.00 DATEOF APPLICATION AROHITECT - SIGNS 6.00 - PLAN CHECK FEE P.C.NO, OR ENGINEER LIC.No, SIGNS TRANS. 3.00 5 A - PERMIT IOATI ON ADDRESS RESS OR ENG. V/1L SPECIAL CIRCUIT . .00 I� ZIP TEMP.METER OR POLE INS. 15.00 I Ar$ ADDRESS MOTORS ,P• SEE FEE SCH. .'C •06 I ADDRESS 1 '/ - SERVICE CHANGE 10.00 4 w O o LICENSED CONTRACTORS DECLARATION a u I hereby affirm that I am licensed under provisions of Chapter 9 1 AE DATE N<a (commencing with Sermon 7000)of Division 3 of the Business and BLDG. E T. PLG. MECH. ' r M i Professions Code ant my license is in full forma rJfcc17.7' ❑ Z o License Class / Lie Number i `!T EJ - 9 m D Datc /� '1 C Contractor ¢ y s BU LDING PERMIT ¢ ¢ w OWNER-BUILDER DECLARATION INFORM TIO . ie °' N I hereby off rm that I am exempt from the Contractor's License MISC.- _ REFER TO ORD F LL o¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6 0 VALVA /FT. w� � Code:Anycily orcounty which requires a permit to construct,alter, ¢ improve,demolish,or repair any structure,prior to its issuance/ TOT also ELEC.CONTR. LIC.NO. ELE DLL requires the applicant for such permit to file a signed statement that I O e w m w he is licensed pursuant to the provisions of the Contractors License F z a Law(Chapter 9 fcommencing will,Section 7000)of Division 3 a]the a i 4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE ¢a j$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. by any applicant for a permit subjects the applicant o a civil penally ALTER-DRAIN -WATER (EA.) 4.00 of not more than five hundred dollars(4500).): ❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC,GROUP RES.UNITS their sole compensation,will do the work,and the structure is not intended or offered to,sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 4.00 Code:The Contractor's License Law dues not apply to an owner of - property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE • himself or through his own employees,provided that such improve- mems are not intended or offered for sale.If,however,lite building GAS-EA.SYSTEM-11NC.40UTLETS 4.00 or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE . prove builder r purposhave the buWen of proving that he did not huild or im- RES IND CON. PB Omer prove fors owner of sale.). INDUSTRIAL WASTE I NTE R. 20.00 ❑ I,as owner of 01e property,he exclusively . 7044,Bu with ❑ - ❑ ❑ ❑ ❑ licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO. and Professions Code:The Contractors License Law does not apply to antr ctsowner offor such property who builds t r improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts for such projects with a conlractor(s)licensed pursuant In the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO, PARCEL NO. O lamexempt under Sec.-,IL&P.0 lot this WATER HEATER W/VENT 4.00 - reason Date Owr WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO. DE vWAhM WORKERS'COMPENSAI'ION UECLARA'1'sION WATER TREATING EQUIP. 4.00 I hereby affirm that I have a certificate of consent to self-insure. ZONING or a ceilificate of Workers'Compensation Insurance,or a certified ENG.SITE NO. copy thereof(Sec,3800,Lab.C.). Policy No, Company O Aii died Copy is hereby furnished. FIRE BPRINK ENERGY TQC Z 2 Certified copy 'is Bled with the city inspection division. MISC.- REFER TO ORD. ❑ N❑ Y ❑ -N❑ = T CERTIFICATE OI'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C. Ul > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. CL a (Phis section need,not be completed if the permit is far one TOTAL Y❑ N❑ Y ❑ N❑ 2 hundred dollars(S 100)or less.) V O 1 certify that in the performance oI'Il,e work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY LL I. mil is issued, I shall not employ any person in any mannersas to U become subject to the Workers'Compensation Laws of California. Do Date ApplicantALTER OR ADD TO MECH. 4.00 BUILDING } N NOTICE TO APPLICANT: If,after making this Certificate of Ex- Z emption,you should become subject 10 the Workers Compensation.. APPLIANCE' 4.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply with FEE U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00 CONSTRUCTION LENDING AGI2NCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE I hereby affirm that there is a Construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 the performance of the work for which this permit is issued(Sec. MICROFILM 3097,CP.C.). HEATING UNIT(TO 100,000 B.T.U.) . 4.00 Lender's Name HEATING UNIT 100,000 B.T.U.)7.50 g, Lender's Address ELECTRIC f certify that l haveread thisapplicalion and slate that the above VENTILATION FAN (SINGLE) 3.00 into rnalion is coriecl. I'agree 10 comply will,all city and coumy - PLUMBING ordinances and state laws relating to building construction. and BOILER-COMP I3 H.P.Dr 100,000 B.T.U., 4.00 hereby autlwriLe representatives of this city to enter upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL above-mentioned properly I'or inocction purposes. (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. - Cupertino against liabilities,judgments, costs and expeases,whiclt CONST.TAX ITS in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00 ' R OL Of ya�pe MECH.CONT. LIC.NO. MECH, tai.. y (�^Z-$3 TOTAL TOTAL /� or) S azure Of Applicant/Contmetor Date OFFICE COPY - -