6387 _ CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
PERMIT ISSUED DATE "ELECTRICAL DATE INSP.'
ulIn
c!Ur
Plumbin& Power Pole
Mechanical r un
Temp as ec grin
Solar a s
Fire Sprinkler Ceiling
Sign Fixtures Int/Ext
tors
Misc. Grounding
e ower
Uther
FINAL INSPECTIONS DATE INSP• ot . rove
Gas
Electric
PlumbingPUMBING DATE IA'SP•
panlca
•� o ar Backflow
0oi MclEr—gmmund
rr ate— Underfloor
Plannmg Partialou
Fire Dept. Rough Complete
Health Dept. tioiar Rough
1lding Water *& Insulation
er In aln
o ain
Gas
Uther
BUILDING DATE INSP. Not rove
Pad Certification
Foundation ELECTRICAL DATE TNSP
Pre-Gunite
slab-MiLmbrane Underfloor S.M.
Bond Beam cts nsu atlon
Underfloor 1 rs Fire an ers
ire
Floor tee ace
le owns Grease Duct 4 Hood
Diaphrams One Hour Shaft
elsmecracln Condensate Drain
Wa-lfs- ane s ;Went Anc ora e
Frame ues r
ath UETe—r
,vallboards Int/Ext. of rove
grew s
Other
Net Approved
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
•• BUILDING PROJECT IDENTIFICATION PERMIT NUMBERAPPLICATION & PERMIT
eOILOIrvc S ^7
/ AOO uu BUILDING — ELECTRICAL—PLUMBING—MECHANICAL 6 3
/ OWNn.a . - PLAN CHECK VALIDATION
,/. rvAME DTV. ELECTRIC PERMIT FEE
PITON Sa- 89
rCaa RACTOR UTLETS-SWITCHES-RECEP 5.00/1.00
/ UC,NO. •� LIGHTING FIXTURES 5.00/1.00
ADDRESS ORs �1 PPLIANCES-RESIDENTIAL 4.00
Q Vj PHON 9 PANELS 5.00 DATE OF APPLICATION
Acs NI ECi SIGNS 6.00 PLAN CHECK FEE .NO.
ENGINEER
TO,NO. SIGNS TRANS. 3.00
nooeess ENO' SPECIAL CIRCUIT 5,06 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
ACANTS /S
ADDRESS
EElI MOTORS SEE FEE SCH. VL
SERVICE CHANGE 10.00
w¢� S s g
r 74
o o LICENSIi1)CONI'RACIORS DECLARATION - /�
¢ u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Businessand
r' Nr Dalc fib"' ��—Cnntnclorror a (f c DL}LIJI _ L—f�JI—�IT
P❑Professions Cu% rad my license is in full!
i 0.— License lLic.Numbs,
0 m r.I❑
a m 1 PERMI,T,<ge "I
¢ c w a OWNER-BUILDER DECLARATION AY 1�'
' o' " MISQ— REFER TO ORD JN ATION' '"
w ;u. r I hereby afrm that I am exempt from the Contractor's License - "
u0 Law for the following reasnn.(Sec.7031.5,13min•ssand Profemone VALUATION
— 5 PERMIT ISSUANCE 6.00
Code:Any city or county whkh rc4uircaa permd tomnslnmLalter, I ,Pdl 1110
(w ¢O O Improve,demolish,or repair any slructum,prior to its issuanm,atm ELEC.CONTE. LIC.NO. ELEC. /
ED ,
requires the appBCanl for such permit to Ole a vgned statement that TOTAL PERMIT TO
o. x$ he s lice P d pursuam to the prov siom of the Contractor's Licenx EPS/R �gT
zi Iaw(Cha ler 9 fcommencin with!Section 7000)of Division 3 ofthe e�C.ai)t3ry
s 4ao Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
on H$ the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
so e , by any applicant for a'permit subjects the apphcanl to a civil Penally ALTER-DRAIN -WATER (EA.) 4.00
of not more than Five hundred dollars(S500)J:
❑ I,as owner of the properly,or my I mpbyaes with wages as BACK FLOW PROTECT.-DEVICE 2.00 Disc.eeouP RES.UNITS
their sole compensntiun,will do the work,and the structure is not
intended or offered for sac(Sec. 7044, Bovines and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code: The Contractors Liccme law does not apply to an owner of
property who builds or improves thereon,and who does such work 3 F IXTUR ES-PER TRAP 4.00 ssa Fr.PL0011 AEEA rorAL Aa+EACE
himself or through his own employees,provided that such improve-
memsurenotinlended or offered for sale.IL however,the building GAS-EA-SYSTEM-1 INC-40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA) 7,00
builder will hove the burden of proving that he did not build or im- - . - . BUILDING USE
RES IND CON PB goer
Prove 1,as ofor wneroose
of sale.) h INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
❑ I,as owner of the property,am exclusircly contracting with
licensed contractors to construct the Prosel ISce.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORSPARCEL NO.
and Professions Code I'he Contractors LPccnse Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) im
contracts for such projects with a conlmeturls)licensed purwam l0 SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Cals fiaor'shPTojv Law.
❑ lam exempt under Scc: ,B.&P.C.for this
res on WATER HEATER W/VENT 4,00
Ower Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK 17RS*COMPENSATION DECLARATION ' WATER TREATING 4.00 -
I hereby aflu n teat I have a cerlificme of emoent to ulr-inwre. .
or a Certificate of Workers Cumq:nsation Insurance,Or a cCHIH d ZONING ENG.SITE NO.
copy thereof(Sec.3R00,LaRC,.).� daS/sT /N�JPN� MAY •,L
Policy No. Company_ --
O ❑ Cen J opy is herehy f niched.
Z
➢( Ce f copy ¢ ed
il,l the city inspection Division. FIRE SPRINK ENERGY TQO
H O Applica _ MISC.- O ORD. Y❑ N� Y ❑ N[
CC m CERTIFICATE OF EXEMPTIO FROM WORKERS' PERMIT ISSUANCE 6.00 — FLOOD ZONE A.L.UG.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. (�
CL 0 (This section need not be completed if the permit is for or¢ TOTAL a Y F-1 N� v ND
U 00 hundred dollar,(SI00)or less.)
I certify that in the performance of the work for which this per.
QTY MECHANICAL PERMIT FEE FEE SUMMARY
U_ U mil is issued,I shall not employ any person in any manner so as In
become subject to the Workers Compensation laws urcatil'ornu. }
n
w Date—Applicant - BUILDING J J
} r0NOTICE TO APPLICANIL
ALTER OR ADD TO MECH. q.00 If,alter making this Cenific to of 1?x- s
{— ? moption,you should become subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Latoor Cade, you must Forthwith comply with - - FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1ODMC.F.U.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE
1 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 6 issued(Sec. MICROFILM
3097,Civ.Cf. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Name HEATI NG UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
information is corms. I agree to comply with all city and county, - gpILEFt-CO4�(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and stale laws relating to building ronstraction,
and
hereby amhorize representatives of this city to enter upon the BO OMP
(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby
property rese for inspectionof ibis
pis it,, Ice.`
(We) agiee to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cu against llabilitns,j g rats, costs and expnvca which PERMIT ISSUANCE 3.00 CONST.TAX
y in a y way o e a s id City in consequence of the
rent go this pe o MECH.CONT. LIC.NO. MECH.
WAA 4( TOTAL TOTAL -760
'SijnaIureofAppiOntpuonO.Cl., Dal
OFFICE COPY