9654CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
9654 (RENEWED) 859 BETTE AVE.
PMTTTWG-.- ADDRESS
REMODEL C.F. SWANSON
P=7 mmiz
FINAL INSPECTIONS DATE I INSP.
Gas
Power Pole
Backflow
Underfloor
ELECTRICAL DATE (INSP.
PLUMBING DA'I�' I INSP.
ELECTRICAL DATE I INSP.
►APPL'UCANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
- 1 BUFLDI NG PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - eLECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
09654
BUILDING
ao,o,R,5ss
X5.5 = E A V,e- -
OWpeerr -
NAME _
F. PHDNE N
CITY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CONTRACTORS
UTLETS-SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
LIC, No,
CONTRACTORS
ADDRESS
APPLIANCES 4,00
PANELS 10.00
PHONE
PHONE
DATE OF APPLICATION
ARCHITECT -
OR
PANELS (OVER 200 AMPI 20.007`7
LAN CHECK FEE P.C. NO.
ENGINEER
uc. No.
SIGNS TRANS. 3.00
ADDRESSs ErvG -
SPECIAL CIRCUIT. 5.00
�sYiti VALIDATION
��LLJJ
EMP. METER OR POLE INS. 20.00
ZIP
E P TJVJ
APPLJ
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
t ��
City Of CU
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code; and my license is in full force and effect.
License Class Lic. Number
IBSUAN E DATE
BLDG.
ELECT.
❑ -
PLG. MECH,
❑ ❑
Dale Contractor
OWNER -BUILDER DECLARATIONMISC.-
I hereby affirm that 1 am exempt from the Contractor's License
Law for the following reason. (Sec, 7031.5, BnOnesssnd Professions
Code: Any city or county which requires a permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
INFORMATION BUILDING PERMIT
REFER TO ORD
VALUATION
$/FT.
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT TO
tTi1/B(dJ
QTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Sect ion 7000) of D ivision 3 of the
Business and Professions Code) or that he is exempt therefrom and
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($500).):
ALTER -DRAIN & VENT -WATER (EA.) 5.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
I
DRAINS -FLOOR, ROOF, AREA, COND- 5.00
intended or offered for sale (Sec. 7044, Business and ProfcssionS
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who docs such work
himself or through his own employees, provided that such improve-
meats are not Intended or offered for sale. If, however, the building
FIXTURES - PER TRAP 5.00
So. FT. FLOOR AREA
TOTAL ACREAGE
GAS -EA. SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that h e did not build or im'
Prove for purpose of sale.).
❑ 1, as owner of the property, am exclusively contracting with
. ..
GAS - EASYSTEM -OVER 4 (EA.) 200
BUILDING 115E
RES IND CON PB Omer
❑ ❑ ❑ ❑ ❑
. .
INDUSTRIAL WASTE INTER - 3000
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft 10.00 ,
/
TRACT NO.
PARCEL NO.
❑ tem exempt under Sec.��B.&P.C. for thisreas
on
WATER HEATER W/VENT 6.00
OwnerI'�/� %�i'�.>..�.
WATER SYSTEM 5.00
ACC.DATE
ACC.FILENO.-
WATER TREATING EQUIP. 5.00
WORKERS 'C04P.NSATION DECLARATION
I hereby affirm that I have a certificate ofconsent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lab.C.).
Policy No. Company
❑ Certified copy is hereby furnished.
❑ Certified copy is Bled with the city inspection division.
Applicant
-
FIRE SPRINK
Y ❑ IN E]
ENERGY T-24
Y ❑ N❑
MISC. - REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
PLG. CONTE. LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE
section need not be completed if the permit is for one
y ❑ N ❑
V 1:1 N[](This
hundred dollars ($100) or less.)
1 certify that in the performance of the work for which this per-
MIT is issued, I shall not employ any person in any manner So as to
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
..LL��
✓V
become subject to the Workers'Compensation Laws of California.
Date Applicant -
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex
APPLIANCE 5.00
PLAN CHECK
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you most forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the pf
3097 eC'oCt'nce of the work for which this permit is issued (Sec.
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
11
Lender's Name
Lender's Address
I Certify that l have read this application and state that the above
VENTILATION FAN (SINGLE) 4.00
information is correct I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER- COMP 13 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP IDVBr 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection 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 -..Co. agains aid City in consequence of the
PERMIT ISSUANCE 10.00
4�rant g 2LW +r'5- O/
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
3
Signature of Applican /C°ontractor ate
OFFICE COPY