4960 CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
E
ADDRESS �
.
FRUJECTi o✓ �����
PERMIT ISSUED DATE ELECTRICAL DATE INSP,'
Pu
i . in a
ectnca yL
ming Power Pole
eFf chanicaler oun
e as ec ougg iring
bolar Wills
FireSprinkler ei in
'Sign ixtures nt xt
Rotors
Misc. Groundin
emp Power
-Other
FINAL INSPECTIONS DATE INSP, Not Approved
Gas
Electric
pl—u-nBing PLUMBING DATE INSP.
Mechanical
anica
o ar Backflow
oun
r
ra in er r 000r.. . .
armingPartial ujz
dire pt. Rou=onplete
Rea tri Inept, oar ou
�ui13m ater ' nsu atiori
Other in ain
o rain
Gas
Other
BUILDING DATE INSP, Not Approved
Pad Certification
oun ation ELECTRICAL DATE INSP.
Pre-7—mite
a - em rane Underfloor S.M.
o1�ndBeeam cts nsu ation
Underfloor Girders ire ers
.Floor Steel ire ace
leis Grease Duct & Hood
is rams One our - ia. t
eismec Bracing Condensate Draixi
awls- anelsui ment Anchorage
came ues Com . Air
Ot er
W.ilboards nt xt, of proved
irewa s
ter
Net Approved
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL-POINT PENONLY
BUI LOI NG PROJECT I DENTI FICATION - PERMIT NUMBER
'Ulto IRS APPLICATION & PERMIT n (��^O
nooREss /` T �!v
e,, M# GYJow BUILDING - ELECTRICAL-PLUMBING-MECHANICAL .
OWNER 5
PLAN CHECK VALIDATION
^ NA`ME ITV. ELECTRIC PERMIT FEE _
PHONE
CONTRACTOR'S • UTLETS-SWITCHES:RECEP 5.00/1.00
011. Q LIGHTING FIXTURES - 5.00/1.00 _
aooe sroR's '.,APPLIANCES-RESIDENTIAL 4.00 +
/�CJ GDEHONE O/ PANELS 5.00 DATE OF A PPLICATION
CwTECT SIGNS, 6.00 'PLAN CHECK FEE P.C.NO,
OR
ENGINEER
LIC.NO.` SIGNS TRANS. 3.00
ADDRESS ENG SPECIAL CIRC,U IT 5.00 .PERMIT VALIDATION
T' ZIP EMP.METER�OR POL INS, r 15.00 • 'P
APPLICANT'SMOTORS . §EE:f`EE`SCH.
ADDRESS
.
SERVICE CHANGt 10.00 FEB
0 o LICENSED CONTRACTORS DECLARATION
- ftIRO r
rt ta U 'I hereby affirm that I ran licensed under provisions of Chapter 9 OISIDA `r
(conune.eing with Section 7000)of Division 3 of the Bowness and BL PLG. MECH.
�,Vs Professions Cole y nd Itcense is in full fore"arid yfJt
Z o N - License Class_ - Lic.Number-LjJ 4f2 0 ❑
m,H w Datc�O P_ �.� _Comractor_�A —�
BUILDING PERMIT
tC ¢ ¢ OWNER—BUILDER DECLARATION • "
Ao> U MISC.- REFER TO ORD INFORMATION
w g N I hereby affirm That I um exempt from the Contractor's License VALUATION $/FT.
F u o¢ Law for the following reason.(Sec,7031.5,Businessaod Professions PERMIT ISSUANCE 6.00
wvs Code:Any city or county which requires a permit to construct,alter; �—^'
¢QO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. .LIC.NO. ELEC. 'd
O LL requires the applicant for such permit to file a signed'statement that TOTAL a PERMIT TO
A. w m he is licensed pursuant tgthe,provisions of the Contractors License
F z aLaw,(Chapter 9(cummeneing with Section 7000)of Division 3 ofthe - 'I C!<YOQEL
Business and Professions Codc)or Brat he is exempt therefrom and OTV. PLUMBING PERMIT- FEE
Ser$ the basis for the alleged exemption,Any violation of Section 7031.5 _ STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant Ina civil penalty ALTER-DRAIN -WATER (EA.)of not more tbhn five hundred dollars IS500)d', -
"❑ I,as owner of the property,or my employees with wagesas 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 for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Cade:The Contractor's License Law does not apply to an..net of
property who funds or improves thereon,and who dues such work FIXTURES:PER TRAP ' 4.00 SQ 7,FLOO't AREA. TOTAL ACR SAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner. GAS-EA.SYSTEM-OVER 4 IEA.) ' 1.00 BUILDING USE
I builder,will have Bm burden'oD proving that in,did not build or int
prove for purpose of sale.). INDUSTRIAL WASTE INTER2000 'RES IND CON PB One,
0 I,as owner of the property,am exclusively contracting wish . .
❑ ❑ ❑ • ❑ ❑
licensed contraetors;tn 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 dues not apply
to an owner of property who Builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1,00,
contracts forsuch projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 ' TRACT NO:, PARCEL NO,
❑ lam exenlpt under Sec. ,N.&I'.C.for this WATER,HEATER 111 4.00
reason
Date Ownef WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO.
WORKS RS'COMPENSA'riON DECLARATION WATER TREATING EQUIP. 4,00
v
I hereby affirm that I have a certificate n of co@ent ors Certified
ZONING ENG,SITE NO.
or a certificate of Workers'Compensation Insurance.or a cenifieJ
copy thereof(Sea 3ACo parry ). - -Policy No.rt Company
❑ Certified copy is hereby furnished.. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y.❑ - N❑ Y❑ N❑'
� y CERTIFICATE OFdEXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A,L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
CL 0 (This section need not be completed if the permit is for one _ TOTAL Y❑ N❑ Y❑ IN C:]
::)'Z hand and dollars(S 100)or less.) .
U'O I certify that in the performahcerof the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued,I sl 11 not employ any person ib any anter so asm
become su�le�t/ tl}e Workers'Compen'tionyaw fCNli(omia. sa
U a Date_�77�'_FJ.lJ-9Applicantj_Y,.- `(� ALTEfl OR MECH. 4.00 BUILDING as
} N NOTI P T A'I'LICAN'I': If,otter muking tllisCert ifieutt of IIx " -
F Z emption',you should become subject to the Worken,Compensation App LI AN 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply wish - FEE -
U such provisions or this permit shall be deemed revoked. AIR HAN G NIT(�TIQ000GF.M.) 3.00
t CONSTRUCT']ON LENDING AGENCY AIR HA U IT(OVER 10,000OF.M.) 5.00 -SEISMIC FEE s-O
I hereby affirm that there-is a construction lending agency for EXHAUST HO IT CT) 2.00
the performance 0f The work for which this permit is issued ISec. MICROFILM
3097,r's Nam '4 )) e- - HEATIN ) 100,000 B.T.U.) 4.00
Lender's Name -JGL'[ HEATING UNIT(OV ER 100,000 B.T.U.17.50
' Lender's Address ELECTRIC
I certify that I have read if pplication anA state that Ilm above VENTILATION FAN (SINGLE) 3.00
information is correct. I e to comply with all oily and county a .PLUMBING - r '
ordinances and sate P s luting m din construction, and __ BOILER-COMP(3.H.P.,or100,000B.T.U.) 4.00
hereby uuthor0c re a atives t ' a'enter upon the 'BOILER-COMP IOver t00,0008TU1 SEE FEE SCH, .MECHANICAL
above lnc agree to p pe y for i e' p„r,,oses.
'(We) agree t Sar , in IT J keep harmless the City of MISC.- REFER TO ORD.
Cupertino aga' s a iii' s, ' ants, costs and expenses which �R _ CONST.TAX ..
may in any Seer ” insaid City in consequa o he PERMIT ISSUANCE 3:00
granting of corm MECH,CONT. LIQ NO'. MECH. O..D -•
TOTAIC 8' TOTAL
,.r
nature of Applicint/Cn ae at
OFFICE COPY