3659 CITY 017 CUl'I:I.TINO INSPESTIOU RECORD (Office Copy)
(� —ALA 196110 Blaney Drive SD)
PERMIT NO. SANITARY DIST. NO. _ LOT NO. ADDRESS
RE-Model Property Services
PROJECT OWNER JOB SITE PHONE NO.
PERMIT ISSUED Date ELECTRICAL
Buildin Date Insp.
Electrical ]' `
ower Pole
Plumhinr• Under -,round
IIcchanical
RouWiring _
Cas/ElecIalh
Temp. /
Solnr Ceilinp
Fire Sprinkler Fixtures Int/Ext
Sign Motors
Grounding
hist. Temp. Power
Other
FINAL. INSPECTIONS Not Approved
Date Insp.
GF.a _
PLUMBING
Electric Z 51 ge Date Insp.
Plumbing Backflow
Mechanical _ 5, R rground
Solar Underfloor
Pnni Partial Rough
Grading Rough Complete
Planning Solar Rough
Fire Dept. Water & Insulation
Health Dept. Main Drain
nuilding R/of/S Drain
Other Gas
Other
BUILDING Not Approved
Date Insp.
Pad Certification MECHANICAL
Foundation Date Insp.
Pre-Gunite Underfloor S.M.
Slab-Membrane Ducts & Insulation _
Bond Beam Fire Dampers
Underf.lnor Girders Fireplace
Floor Steel Grease Duct & hood
Tiedowns _ One flour Shaft
Diaphrams Condensate Drain
Seismic Bracing Equipment Anchorage
Ilalls-Panels Flues & Comb. Air
Frame 7 - / • 93 Other
Lath Not Approved
Uallboards Int/Ext.
Firewalls
Other
Not A2proved
>/ h
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGJ APPLICATION & PERMIT 3659
ADD SS
6 NG
•' G BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'5 PLAN CHECK VALIDATION
,L W(? TV. ELECTRIC PERMIT FEE
I
Nauss
vnOrvE
owT AcrOR' OUTLETS-SWITCHES-RECEP 5.00/1.00
uC NO. LIGHTING FIXTURES 5.00/1.00
ADDRESS TOR'. APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. PAID3.00
ARC Ess END SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zIP EMP.METER OR PO .00
T
APPLICANS MOTORS
ADDRESS SEE FEE SCH.
¢ i �ye
SERVICE CHANGE .00
a: (commencing with Section 7000)of Division 3 of the Business and3
o
Foo LICENSED CONTRACTORS DIiCLARATION
a u 1 hereby affirm Ihut I am licensed under provisions ofChapter 9 ISSUANCE E
w
ti a u BLDG. ELECT. MECH.
r H z Professions Code,and my license is in full farce and effect ❑ ❑
Z 0- W License Class Lic.Number
H y H Date Contractor
¢ ¢ w u OWNER-BUILDER DECLARATION B1INFORMATION11,0411110 I
w ; ¢ F. I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
Fuoj law for the following reason(Sec.7031.5,Business and Professions -PERMIT ISSUANCE 600 6 /' VALUAT 11 Of UpWI
no
Cade:Any city or county which requires a permit to construct,alter, [!_Y[J
ELEC.CONTR. LIC.NO.
Q Qat improve,defnahifh or repair SINCInre,prior to 1t515NanCC.a Sn ELEC r� C)0 /D '
O er requires the applicant for such permit to file a signed statement that TOTAL .,{ PERMIT 70
¢ w es U.u he is licensed pursuant to the provisions of the Ciadunctor's License C!J/
Fi) Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
3 z o Business and Professions Code)or that he Is exempt therefrom and OTV. PLUMBING PERMIT FEE ��t) e
¢ F the basis for lite alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3by any applicant fora permit subjectsthe applicant toacivilpcnally ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred doll...155001.1:
❑ 1,as owner of the property,or my employees with wageses 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
Code:The Contractor's License Law does not apply to an owner of
property who builds or Improve.Thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.IT.FLOOR AREA TOTAL ACREAGE
himself'or through his own employees,provided that such improve.
merits are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 4.00
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
prove 1,aso neeose nl the.l. - INDUSTRIAL WASTE'INTER. 20.00 ❑ ❑ ❑ ED ❑
❑ I,as owner of the properly,um exclusively contracting with
licensed contractors t0 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 does not apply
to an owner of property who builds or imprmxs thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
cInttr.cts for such projects wish a co tramons)licensed pursumt to O
the Contractor's License L.W. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL No.
❑ lam exempt under Sec.-,It for this WATER HEATER W/VENT 4.00
reason�_ �p
Daze (w-=_/�''.,1, Ownc _ _ WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPF.NSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby utflrm that I have a certificate oleonsent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,L.b.C.f -
Policy No. Company
O ❑ Certified Copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z 2 ❑ Certified copy is filed with the city inspection division. MISC.' REFER TO ORD.
0 Applicant Y ❑ NE] Y ❑ N�
CE RTI FICATE 017 F.XI'.MPI]ON PROM WORK Ii RS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U,C.
LU COGIPENSATION INSURANCE PLG.CONTR. LIC,NO. PLG.
CL Z fThis sectidm need not be Completed it the permit is for one TOTAL Y❑ N Y [] N
hundred dollars IS 100)orlesx.)
U 0 I certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shalt not anploy any person in any mumer so as to
become subject to the Workers'Compensation Laws of Calil'onia. /
O W Datc Applicant Q ALTER OR ADD TO MECH. 4.00 BUILDING �
} W NOTICE TO APPLICANT: It,after making this Certificate of Ex-
F. ? emption,you should became subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1G=CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the perfornwnce 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 Address
HEATING UNIT(OVER 100,000 B.T.U.)7.50 e�SG�
Lender's Address ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
hereby
and slate laws relating to building construction, and
hereby titnd property for inspection put, es.
representatives c this city to enter upon the
abovmmenentioned BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
os
(We) agree m save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs nod expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way Sec,u agai t said City in consequence of the
I,per - MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL 14
'gn.tum of p lican[ ntraCtnr Uutu
OFFICE COPY