7129 (2) CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
• txxlinDuu111 NO. — �
OWNER
PERMIT ISSUED DATE "ELECTRICAL DATE INSP;
NTdinp: --
Elctrical
Plumbing Power Pole
anica r un
Temp as ec u irin
Solar Walls
Fire Sprinkler ei ut
Sign Fixtures nt xt
motors
Misc. Grounding
= e Power
Other
FINAL INSPECTIONS DATE INSP. Not ,Approved
Gas
Erectric
Plumbin,R PMIBING DATE INSP.
and-ca
Solar Backflow
ool Underground
Grading r oor
FlanninR mart^ia ou
Fire Dept. fou ete
eat a t. ar u
u ding water ' ns ation
Uther ut ain
o am
Gas
.Dther
BUILDING DATE INSP. Not rove
Pad Certification
Foundation ELECTRICAL DATE INSP.
re- unite
Slab-Ntmbrane Underfloor S.M.
BondBearn Ducts & Insulation
Under±loo,r Girders Fire Dam ers
Floor tee Fireace
Ti"e-23 vns Grease ouct & Hood
i.a rams a our t
eismecracin on nsate Drain
WErls- ane s m Anchorage
ram Flues r
atm—
father —
4a, l Loar nt/Ext. Not Approved
L-rewalls
Other
Net rove
APeLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
RIJRUING APPLICATION & PERMIT n
ADDRESS
N BUILDING-ELECTRICAL-PLUMBING-MECHANICAL •
129
OWNER g ' ifY, b PLAN CHECK VALIDATION
i
4Y ': - y
L� '�� OT}VF, ' ,{ - sELECTRIC PERMIT a �FEEj
PHONE {
.CONTRACTOR'S
N E OUTLETS-SWITCHES-RECEP 5.00/1.00
0 S j LIC.No Q LIGHTING FIXTURES 5.00/1.00
COORFDDREssACron's a
APPLIANCES-RESIDENTIAL 4,00 -
/J�/f �/�/
C/70 A L/A PHONE TTI •/J/ PANELS 5.00 DATEOFAPPLICATION
ARCHITECT PLAN CHECK FEE - I P.C:NO.
on SIGNS 6.00
ENGINEER '
LIC,NO. SIGNS TRANS. 3.00 '•- '
AooeEss ENc. SPECIAL CIRCUIT 5.00 eY'a�` PERFyyILIQ�TION
ZIP EMP.METER OR POLE INS. 15.00 _ /•��1Y�
ADDRESS rs' MOTORS SEE FEE SCH. . rJQN 2 2 i9�r
ADDRESS 2L I / C.' s1 - ,
O SERVICE CHANG 10.00 1
w 0 z. - C1tY 0f CU
F o o LICIiNS1iD CONTRACTORS DIiCLARATIDN PerGUo
a u w I hereby affirm that [am licensed under provisions of Chaplet 9 ISSUANCE DATE
z (commencing with Section 7000)of Division 3 of the Business and
ti ¢ H �� BL ELE PLG. MECH.
Professions Cade,: m license is in full fore y� I ❑ ❑
.F = v"i Date
Class_ y CRTNumber�fL� '
w - Dale �.LZConlraclor
a m E ms+ Ie !� /r��, r BUI DINGiPERM1T
¢ 0 w a OWNER-BUILDER UEC R�Q�GfN /��
n o a u I-_;URNIdTj10N :
w g 0 r Iherebyffile
affirm that 1 am exempt from thio Contractor's Liwnsc MISC.- REFER TO ORD
LL o J Law for Die Ibllowin•reason.(Sec.7031.5,Business and Professions VALUATION E/FT.
_ 6 PERMIT ISSUANCE 6.00 -�'
Code:Any city or county which requiresa permit to construct,nil.
rc ¢0 impinve,demolish;or repair any structure,prior to its isaiance,also ELEC.CONTH. LIC.NO. ELEC. /
n w m u requires the applicant for such permit to file a signed statement th.1 TOTAL PE MIT TO
he is licensed pursuant to the provisions of the Contractor's License
riQ Law(Chapter 9(commencing with Section 7000)ofDlviston3oftla a ' I , t} m _ a k,%'4 `yam: T
H usinem and Pro lessons Code)or that he is exem pt therefrom and GLV, PLUMBING,PERMIT, FEE
¢10 the basis for l he alleged ex cm pt ion An y vlolal ion of Section 70315 ski ' i �, t 't, a .'- ;.t f'.`�:/ ' STORIES T O�[1STR.
i i .- by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
(j
of not more than five hundred dollars($500),): •-
❑,. I,as owner of the property,or my employees with w9ges as BACK FLOW thPROTECT.DEVICE 2.00 OCC.GROUP, RES.UNITS
their sole compensation,will do e work,and the structure is not
tended or offered for lute (Sec. 7044, Businciai 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 does such work F IXTUR ES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
Tents re nut
own rodfu df or Sale.If,ed however,[lie
improve GAS-EA.SYSTEM-1 4.00
menus ore not intended or offered for sale.If,mplevcq the building
lir improvement is sold within one year of completion,an[ sire owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did an[build m im-
prove for,purposeofsali,). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Orion,
❑ 1,'as owner of the property.am exclusively contracting with ❑ ❑ ❑ ❑ ❑ ,
licensed'contractors to construct Ihe'project(See.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. . 5.00 ASSESSORS PARCEL NO.
Rod
Ptofesslain Code:The Contractors License Law does not apply
to an owner of property who builds or improves thereon,and who - LAWN SPRINKLERS-OVER 5(EA.) 1,00
Contracts for such projects with a contractons)licensed pursuant los SEWER-SANITARY-STORM EA.200ft/6.00
the Conlraclor'z Liccnsc'law. . '• - TRACT NO. PARCEL NO.
❑ I an exempt made,Sec. ,B.AP.Cl for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4,00
. ACC.DATE ACC.FILE NO.
WORK E RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I herebyalftrm that I have a cerliticale•ate...Rant to self-insure, - ZONING ENG.SITE NO.
ora Certificate of Workers'Compensation Insurance,ora certified
copy thereof(Sec.3800,Lab,CJ. `
Policy No. Cmnpaly_S ! 1!!!e0.
❑ CceRlcdcapylsher unshod. " FIRE SPRINK ENERGY T-74z Z d.ERified "spy •with the cit pectiot division. - - -
p Applivant __�- ' �� .' MISC.- REFER TO ORD. v❑ No , Y N❑
T CERT It IC '01:EXEMPTION FROM WORKERSPERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU'> COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
0 (This Ls Section need nal be completed if IT, permit nl is fr i e " TOTAL Y E] NCIN❑ Y❑ N
hundr d dollurs(S1000orless.) ,w
U O 1 certify that In Bre performance of the work for which this M.r OTVr' ,.' MECHANICAL PERMIT FEE ```rFEE�SUMNI�A�RV-
LL U nal is issued,I shall not employ any person In any manner so as to g * j - . } k „rb
become subject to the Worken'Compensation Laws of California. /!
n Dale Applicant ALTER OR - ( W
} In NOTICE TO APPLICANT: It after making Oiis CeHificale of Ex- ADD TO MECH. q,00 BUILDING
v
F Z emption:,you should become subject to the Workers Compensation APPLIANCE' 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V such provisions of this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=11F.M.) 3.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10OOC.RM.) 5.00 SEISMIC FEE r
I hereby affirm that there is a Construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
lire performance of the work for which this permit is issued(Sec. MICROFILM
- 3097,Civ.C.).` HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's a HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lenders Add Address ELECTRIC
orma;fy that l have read
agrees application and all c that d county VENTILATION FAN (SINGLE) 3.00
information is correct I agree to comply with all city and county PLUMBING
nrdinances and,smte laws relating to building canatruction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspectionpurposes. BOILERpCOMB(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
,
(We) agree io save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
M..
Secure against said City in consequence o the
rmit. MECH.CONT. -LIC.NO. MECH:
G G T°TA` TOTAL r
cant/C r Dale
,OFFICE COPY