29811 CITY OF CUPS?RT'1NO INSPECTIOV RE-CORD (Office Copy)
10700 Blaney Ave._ 11698-D
\/k PI:Ili IIT NO. SANITARY DIST. NO. LOT NO. � ADUIIFSS
_ Fire Damage Property Services
PROJECT ONNER JOB SITE PHONE NO.
PERMIT ISSUED Date ELECTRICAL
Bu Lldinr. -----12-23-82 Date Insp.
1:1ectrical 12-23-82 Power Pole _
Plumping LlndcrfrOuncl _
itechanicat
12-23-T2 Rough Wiring
'Temp. Gas/1?sect. IIaI.Is _---
Solar Ceiling
Fire S rinkler _ Fixtures Int/Ext
Si .,n Ilotors
Grounding
Misc. Temp. Power _
Other
FINAL. INSPECTIONS Not Approved _
Date Insp.
Electric lectric
Date Insp.
Plumbing Backflow
'Iechanical Underground
Solar Underfloor _
Pool Partial. Rough
Grading Rough Complete
Planning Solar Rough
!
Fire Dept. water & Insulation
-- l Health Dept. ".fain Drain
Building R/of/S Drain _
Other Gas _
Other
BUILDING Not Approved
Date Insp.
Pad Certification MECHANICAL
Foundation Date Insp.
Pre-Gunite Underfloor S.H.
Sl.ah-Membrane Ducts & Insulation
Bond Beam Fire Dampers _
Underfloor Girders Fireplace _
Floor Steel Grease Duct & Ilood
Tiedowns One Hour Shaft
D.iaphrams Condensate Drain
Seismic Bracing; Equipment Anchorage
Ila] Is-Panels Flues & Comb. Air
]game Other
Lath Not Approved
Ilallboards Int/Ext.
Firewalls
Other
Not A roved
APPLICANT TO FILL IN INFORMATION WITHIN RED.LINES - USE BALL POINT PEN ONLY
r
. 2•'
BU LOI NG PROJECT I DEN71 FICATION PERMIT Nu BE
9UILDING APPLICATION & PERMIT
ADDRESS _ /I
1�'`(e5 -7J BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
NAME ELECTRIC PERMIT FEE PLAN CHECK VALIDATION
OTS'•
i • � r1VQU1fE4 PRDNE
NAME P`z`q 1-L HL¢cr0.kt� _ OUTLETS-SWITCHES-RECEP 5.00/1.00 ro ,
uc.No. LIGHTING FIXTURES 5.00/1.00
DDGRESSRESS
PPLIANCES-RESIDENTIAL 4.00
A
ARCHITECT PHONE PANELS 5.00 DATE OF APPLICATION
OR SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER '
uc.'No. SIGNS TRANS. 3.00
A RCH.OR ENQ
' a00RE55 SPECIAL CIRCUIT 500 PERMIT VALIDATION -
zIP EMP-METER OR POLE INS. 15.00 /7
APPLICANT'S /(�JpS
aooREss MOTORS SEE FEE SCH.
S• - SERVICE CHANGE 10.00
D ¢ _ is .
r
00 LICENSED CONTRACTORS DECLARATION
¢ w
wi� 1 hereby affirm that I am licensed under n 3 of the of Chapter 9 ISSUANCE DATE
rt A (commencing with Section 7000)of Division 3 of the Business and
r
Ps Code,and my license is in full force and effect. BLDG. ELECT. PLG. MECH.
z m
o w License Class Lle.Nuber
o y o Dale 1-2
Contractor ❑ ❑
a ¢ w OWNER-BUILDER DECLARATION - _BUILDING PERMIT
X ; ' I hereby affirm Bud 1 am exempt from the Contractor's License MISC.- REFER TO ORD INFORMATION
F P_ O .Qi Law for the following reason.(Sec.7031.5,Business and Professions e-e VALUATION $/FT. .
y PERMIT ISSUANCE
� my � Code:Any city or county which requiresapermino construe[,alter, 6.00
¢ ¢ 6 O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH, LIC.NO. �n
¢ requires the applicant for such permit to file a signed statement that ELEC. Soy
w Ps�` he is licensed pursuant to the provisions of the Contractor's License TOTAL p7 PERMIT TO
r z < Law(Chapter9(commencingwilh Section7000)of Division3ofthe
CE 4 o Badness and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE h-L/
¢ I- o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE C STIR.aim by any applicant for a permit subjectsthe applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of t more than five hundred dollars(8500).1:
1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE
reit sole compensation,will do the work,andthe S mature is not 2.QQ OCC.GROUP S.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Cade:The Contractor's License Law does flat apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4,00
himselEor through his awn employees,provided that Such improve-
ments FLOOR are not intended or offered for sale.If,however,the building 'GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner-
builder ri
will have the harden of proving that he did not build or im, GAS-EA.SYSTEM-OVER 4 (EA.) 7.00 BUILDING USE
/ prove for as owner of sale.). INDUSTRIAL WASTE INTER. RES IND CON PB Omer
1\ ❑ Las owner of the property,um exclusively contracting with 20.00 ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 5.00
and Professions Code:TPRM
ntractor s License Law does not.apply 'ASSESSORS PARCEL NO.
to an owner of propertbuilds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA,) 1.00
contracts for such pmjeth a contractor(,)licensed pursuant m
the Contractor's License SEWER-SANITARY-STORM EA. 200ft/6.00 TRACT NO, PARCEL NO.
yea❑nl em exempt a nd -�00�4 RM
WATER HEATER W/VENT
4.00
Date Conor WATER SYSTEM4.00 ACC.DATE ACC.FILE NO.
hat N9AT1oN D:CLARAT( WATER TREATING EQUIP. 4.00I he[eby affirm that a certificate of conseta to self-insure.a certificate of Workompensation Insurance,or a certified 20NINGENG.SITE NOcopy thereof)Sec.3800 .).Policy No. CoO ❑ Certified copy is hfurnished. -
z ❑ Certified copy isewith the city inspection doision. RE SPRINK ENERGY T-�4
H Applicata MISC.- REFER TO ORD. v ❑ N❑ Y ❑ N❑
O7 W CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00
W > COMPENSATION INSURANCE FLOOD ZONE A.L.0 C.
d 0 PLG.CONTR. LIC NO. PLG.
(Thi, section need not he completed if the permit is for one TOTAL Y❑ IN 1:1 Y❑ N❑
O hundred dollars(8100)or less.)
I certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE SUMMARY
LL F mit is issued,I shall nal employ any person in any Inature,so as to FEE
O w become subject to the Workers'Compensation Laws of California.
IS. Dale Applicata ALTER OR ADD TO MECH. 4.00 BUILDING
} Z NOTICE TO APPLICANT'. If,after making this Certificate of ion
F _ em visionon,you should become subject In the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions io the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000GF.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE , �-�
I hereby affirm diet there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
- the performance of the work for which this permit is issued(Sec.
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
Lender's Nome
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC •��
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3A0
4Pmfonnation is Correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COME(3 H.P.or 100,000 B.T.U.) 4.00 -
hereby authorize representatives of this city to enter upon the ��
above-mentioned property for inspection purposes. BOILER-COMP f0sm 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify mW keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, vests and expenses which CONST.TAX
may in any way accrue-against 'lid City Ia consequence of the PERMIT ISSUANCE 3.00 I`e
granting of[his peon -�
MECH.CONT. LIC.NO. MECH.
X1 L OTAL// �y TOTAL �p
Sugnafure of ApplicmrtjCon[actor Due ��
OFFICE COPY iy
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