5823 CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
- - ADDRh66 -LOT NO.
E. d
PERMIT ISSUED DATE ELECTRICAL DATE INSP.'
ui
ecnitrnn ca
Plumbing Power Pole
ticalr�n�
�Temps ec ;M9gr firing
Solar Walls
Fire Sprinkler g r
Sifixtures Int/Ext
tors
Misc. Grounding
e ower
Uther
FINAL INSPECTIONS DATE INSP. of Approved
Gas
Electric
Plumbing - PLUMBING DATE INSP.
anica
o ar Backflow
woo
n
GrPartial or m arti
ou
ire t. u ete
Health t. o ar ou
ui �ig",e4t Water "& ns anon
er in a�.n
o ain
Gas
Other
BUILDING DATE INSP. Not Approved
Pad Certification
Foundation ELECTRICAL DATE INSP. .
sale d �M
blab-Membrane Underfloor S.M.
Bond Beam Mc-t-s-77nsulation
Undertloor i ers� - ire ampers
oor tee Firelace
Tiedowns urease Lxict o0
i,a rams a our Shaft
eismecracin Condensate Drain
Wa-ITs- ane s ui ment Anchorage
r ues 4 UoMb. Air
atm— -J- Zither
3 oars Int/Ex-t. /-p of Approved
lrewal s
Other
Net Approved
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT'.
App RE5/5 ` � '
b7 �(L -ELECTRICAL-PLUMBING,-MECHANICALpW ER' ]BUILDING
Y5823
PLAN CHECK VALIDATION
PHONEELECTRIC PERMIT FEE �1NgMERAc7ons /Lp OUTLETS-SWITCHES-RECEP 5.00/1.00 uc.rvo, O 'j LIGHTING FIXTURES 5.00/1.00 35
ADDRESS
REAAcapgs I APPLIANCES-RESIDENTIAL 4.00
CONTRACTORS
S N PHONEg�S Aot3 PANELS 5.00 DATE OF APPLICATION
r
1j OR
J'�' �,�y_97;brdy SIGNS 6.00 PLAN CHECK FEE P.C.NO,
I NGINEHR�.,/��
LIC.No. SIGNS TRANS. 3.00
J///L.rrrK/ -
TECH,OR ENG. - _•
ADDRESSp �/�, '� SPECIAL CIRCUIT pA .00 PERMIT VALIDATION
60 /L. V,,P / EMP.METER OR POLE INS. T .00
ADDRESS rs FEE SGH>4.
ADDRESS - MOTORS
SERVICE CHANGE tl "' •"1 d.00'
0¢ i
r O 0 LICENSED CONTRACTORS DECLARATION -a a M.CY
a v pe
I hereby affirm that I am licensed under provisions of Chapter 9
m U w (commencing with Section 1000)of Division 3 of the Business and - ISSUANCE DATE
F w 2 Professions Cotte,agyd y license ism full for nd eff•et. BLDG. ELECT. PLG. MECH.
00 i m D License Class G Lia Number O n
H w r J Date Contractor L LG.� ❑ ❑
Q M J BUILDINpiiEERM1T
¢'¢w OWNER-BUILDER DECLARATION - INF RI144�S1kPI 1M
w ;a. 1 hereby affirm that I am exempt from the Contractor's License - MISC.- REFER TO ORD -
F u O s( Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
'PERMIT ISSUANCE 6.00
E a,, Code:Any mulish,ounty it any st uires acame permit o its issuance,
also
¢ T Q improve,demolish,or repair any stiucturo,prior to its issuance,x150 ELEC.CONTE.' LIC.NO:
ELEC. J
w requires the applicant for such permit to file a signed statement That TOTAL MI
e w m Ire is licensed pursuant to the provisions of the Contractor's License PERT TO
rzs- Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe �nO
Z i O Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE rl
¢F$ (he basis for the alleged exemption.Any violation of Section 7031.5STORIES TYPE CONSTR.
ii - by any applicant for a permit subjects the applicant to a civil penalty - ALTER-DRAIN -WATER (EA.) 4.90
of not more([ran five hundred dollars($500).1:
❑ 1,as owner of the Properly,or my employees with wages as BACK FLOW PROTECT.DEV ICE .00
their sole compensation,will do the work,and the structure is nal OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CO 4.00
Code:The Contractor's License Law docs not apply to an owner of
himspropelf
who builds or improves employees,
pr and Wtlo does such work FIXTURES-PER TRAP 4.00 sa FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenot intended or offered for sale.l E however,the building GAS-EA,SYSTEM-11NC.4 TLETS 4.00
or improvement is sold within one year of completion,the owner- -
builder will have the burden of proving that he did no(build or im- GAS'-'EA.SYSTEM-OV 4(EA.) 1,00 . BUILDING USE
prove for Purpose of sale.). INDUSTRIAL WASTETER. 20.00 RES IND CON PB Other
O I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,BusinessLAWN SPRINKLE 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply -
to an owner of property who builds or improves thereon,and who LAWN SPR INK RS-OVER 5(EA.) 7.00
_ contracts for such projects with a contractor(s)licensed pursuant to
the Contractors License Law. SEWER-SAN ARV-STORM EA.2OOft/8.00
❑ TRACT NO. PARCEL NO.
lam exempt under Sec. ,B.4P.C.for this WATERH TER W/VENT ,
reason 4.00
Owner Date WATE YSTEM 4.00
ACC.DATE ACC FILE NO.
' WORKERS'COMPIINSATION DECLARATION WqT TREATING EQUIP. 4.00 '
1 hereby affirm that I have a certificate of consent m self-insure,
ora certificate of Workers'Compensation Insurance,or a certified ,ZONING ENG.SITE NO. '
-copy lhcrspfl ec S ,Lab,C.)�A� � '
Policy Noll• any ANA f•�.
O ❑ Certified copy is hereby furnished. '
Z Z ❑ Certified copy is filed with the city inspection division. FIRE SPRINK ENERGY T 74
O Applicant MISC. REFER TO ORD. y N Y [] NEl
Cr m CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE - 6.00 FLOOD ZONE A.L.u.c.
LU - COMPENSATION INSURANCE PLG.CONTE. ILIC NO. PLG.
C 0 (This section need not be completed if the permit is for one _ _ TOTAL Y[:] N Y 0 N
::) Z h undred dollars IS 100)or less.) -
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL H snit is issued,1 shall not employ any person in any manner so as to
O Ubecome subject to the Workers'Compensation Laws of California.
0. Date Applicant ALTER OR ADD TO MECH. 4BUILDING .���
} Us NOTICE. TO APPLICANT' If,after making this Certificate of Ex-
,
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 00 PLAN CHECK
provisions of tire .
e Labor Code, you must forthwith comply C) FEE such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=C.F .) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10 C.FM.15.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 z
the performance of(he work for which this permit is issued(Sec.
3097,Civ C.). HEATING UNIT(TO100,000 B.T.U.) 4.00 MICROFILM
Lender's Name -
Lender's Address HEATING UNIT( ER 100,000 B.T.U.17.50 ELECTRIC 33
I certify that I have read this application and state that the above VENTILATION AN (SINGLE) 3.00
information is cormcL I agree to comply with all city and county BOILER-CO PLUMBING
Ordinances and state laws relating to building construction, and (3 H.P.Dr 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter uponthe
above-mentioned property for inspection purposes. BOI LE OMP (Ova,100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MIS .- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the MIT ISSUANCE 3.00
gra til 0 tl permit. MECH.CONT. LIC.NO.
V MECH.
Signature4 20A.,A �y� TOTAL TOTAL �,3y!
Signe[u a of lm icant/Cont ctor, ale �.�.�
OFFICE COPY