2045CI'T'Y 01' CUPERT'1N0 IIJSPL'CTI011 RECORD (Office Copy)
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20445 _ 10497 De Anza
PCITIT PTO. SANITARY DIST. No. LOT N0. AUDRP,SS
• Reroof Ron Cali
PROJECT OWNER JOB SITE PHONE NO.
PERMIT ISSUED Date I ELECTRICAL
It
10
Bu L I d I
TA ectr
PLumhi
Nochan
'Iemp .
Solar
Fire S
Misc.
FINAL. INSPECTIONS
-1 :4-82 I Date ( Insp.
BUILDING
Date
Pad Certification
Insp.
Foundation
Pre-Gunite
Slab-Llembrane
Bond Beam
Underfloor Girders
Floor Steel
Tiedowns
_
Diaphrams
Seismic Bracing
Ifalls-Pancls
Frame
L,n th
Uallboards Int/Ext.
Firewalls
Other
Not Approved
Mr -0
h Wi
I
Fixtures Int/Ext
Notors
Grounding
Temp. Power _
Other
PLUMBING
Date
Backflow
Insp.
Underground
Underfloor
Partial Rough
Rough Complete
Solar Rough
Water & Insulation
Main Drain
_
R/of/S Drain
Gas .
Other
Not Approved
MECHANICAL
Date
Underfloor S.M.
Insp.
Ducts & Insulation
Fire Dampers
Fireplace
Grease Duct & hood
One (tour Shaft
Condensate Drain
Equipment Anchorage
Flues & Comb. Air
Other
Not Approved
BUILDING
_s
ELECTRICAL
PLUMBING
MISCELLANEOUS
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU1*D•INGLPROJECT IDENTIFICATION
APPLICATION &PERMIT
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
PERMITN MB
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B LD,Nc
/ooREss
Dt4(34oD
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- -
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
VN<.
-OUTLETS-SWITCHES-RECEP
ND,�LIGHTING
5.00/1.00
FIXTURES 5.00/1.00
S..
PHONE -
APPLIANCES - RESIDENTIAL 4.00
PANELS 5.00
ARCHITECT _
ENGINEEFl
uC. No.
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARC" OR ENG.
ADDRESS
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00
ZIP
,n^n
lI Ssgam
APPUCANT'S
ADDRESS
MOTORS SEE FEE SCH.
L.
SERVICE CHANGE 10.00
-
LICENSIiD CONTRACTORS DIiCLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
Comnin acing with Seclion 7000) of Division 3 of the Business and
Professions Cod an 'ensu is in full Torrqg f ctt//'' //��
License la _ Liu. Number( .(0�
L
ISSUANCE DATE
BLDG.
❑
ELECT.
❑
PLG. MECH.
❑ ❑
Date _ContractorOU
71
BUILDING PERMIT
INFORMATION
OWNER -BUILDER D17CLA I
I hereby cthe ollo that aso exempt li1.D,tl • Businessand P s l-icume
Professions
Law lO Any
greywhichn. e. requires a permit to construct,
Code. Any city or county which requires permit toconsuanc alter,
MISC.- REFER TO ORD
VALUATION
P-r�
$/FT.
PERMIT ISSUANCE - 6.00
ELEC. CONTE. LIC. NO. ELEC.
TOTAL
to its issuance, also
improve, demolish,appicant repair such y structure. prior signed
for such permit to fill a signed statement that
requires the dp pursuant
he is licensed pursuant the provisions of the Contractor'sviion License
/ �d•
PERMIT TO
QTY. PLUMBING PERMIT FEE
en
Busi (ess and 9(commencingwi sh Shaine is7000) D ivision3of and
Business and Professions Code) or That he is exempt therefrom and
exempt
TORIES
TYPE CONSTR.
the for the alleged exemption. Any of Section
by any applicant fora permit subjects the0).)i and loacivil penally
any a subjects applicant malty
of not more than five hundred dollars (55
ALTER-DRAIN-WATER(EA.)4.00
O Lemployees owner the property, or my employees with wages as
their sole compensation,
ion, will do the work, and the structure is not
BACK FLOW PROTECT. DEV ICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
intended or offered for sale (Sec. 7044, Business and an owner of
Code: The Contractor's License Law docs not loan owner of
FIXTURES -PER TRAP 4.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
h
property who builds or improves Thereon, and who does such work
f who
himself or through his own employees, provided that such improve
ments are not intended or offered for sale. IL however, the building
GAS-EA.SYSTEM-11NC.4OUTLETS 4.00
or improvement is Sold within one year of completion the owner-
builder will have the burden of proving that he did not build or int
prove for purpose ofsule.).
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 IEA.1 1.00
BUILDING USE
RES IND CON PB Other
❑ ❑ ❑ ❑ ❑
INDUSTRIAL W I TER. 20.00
licensed contractors 10 construct the project (Sec. 7044, Business
and Professions Code The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon, and who
LAWN SPRINKL .OUTiDD
ASSESSORS PARCEL NO. '
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contraels for such projects with a contractors) lice...... pnrnl.... to
the Cortmaor's License Law,
Si
TRACT NO,
PARCEL NO.
❑ tum exempt under Sec.-, BAP.C. fix this
WATER HEATER W/VENT 4.00
on
Dale Owner
WATER SYSTEM FAID 4.00
ACC.DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORK Ii RS' COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent 10 sell -insure,
a certificate of Workers' Compensnynn Insurance, ar a c,rHP.
copy there S c. ,vLa / / ip .i_�._
ZONING
ENG. SITE NO.
;12
Policy mil p-,fy" c _7-4
FIRE SPRINK
v❑ N❑
ENERGY T-24
Y N❑
Cl Certified copy is hereby fur ,z •d.
❑ Certified py A, led h I• ioI rh n.
Applicant
MISC.- REFER TO ORD.
CERTIFICATE OI' EXEMPTION PROM WORKS. RS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
PLG. CONTE. LIC. NO.
PLG. .
TOTAL
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
Y ❑ r, NE]
Y [:]N❑
hundred dollars ($100) or less,) -
I certify that in the performance of the work for which this per-
mil is issued, I shall not employ any peison in any manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
v
O L/
become subject to the Workers' Compertsation Laws of Culitorniu.
Date- Applicant -
NOTICE TO APPLICANT: If, after making this Certificate of E x-
ALTER OR ADD TO MECH. - 4,00
APPLIANCE 4.00
PLAN CHECK
eption, you Should become Subject t0 the Workers' Compensation
m
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked
FEE
AIR HANDLING UNIT ITO 10=C.F.M.) 3.00
AIR HANDLING UNITIOVER I0,000C.F.M.) 5.00
-SEISMICFEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
'
the performance 0f the work for which this permit ie issued (Sec.
3097, Civ.C. ).
MICROFILM
HEATING UNIT dTO 100,000 B.T.U.1 4.00
HEATI NG UN IT (OVER 100,000 B.T.U.)7.50
ELECTRIC
Lenders Name
Lender's Address
I certify that l have read this application and smte that file above
information is correct. I agree to comply with all city and county
oNinun ces and stale laws rclutimg to building construction, and
-VENTILATION FAN (SINGLE) 3.00
PLUMBING
-
BOILER-COMP13 H. P. or 100,000 B.T. U.1 4.00
BOILER -COMP (Over I00,000BTUI SEE FEESCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
,floor mentioned property for inspaulian purposes„
MISC. - REFER TO ORD.
CONST. TAX
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said 'ty in conserve Ce of the
.Bata' of this mall y
r�V
\
PERMIT ISSUANCE 3.00
MECH. CONT. LIC. NO.
-
TOTAL
MECH.1P
TOTAL
e(/
Signatureof Applicant/Contractor I Dal
OFFICE COPY