3393CITY OF CUPYRTINO INSPECTI01! RECORD (Office Copy)
3393
. PEPJIIT 110. SANITARY DIST. 110,
Ansul System
PROJECT
•
•
10889 S. Blaney Avenue
LOT NO• ADDRESS
JACK & JILL
OWNER JOB SITE PHONE NO.
PEMIT ISSUED
Date
BuiJdinr•
EJectrical
_
I'lumhinr,
llcchanical
'Penh. Cas/I'lect.
Solar
Fire Sprinkler
Sign
Hisc.
FINAL INSPECTIONS
Date
�, � s _
Insp.
Electric
Plumbin,
Mechanical
Solar
Pool
Crarlin
Planning
Fire Dept.
Health De t.
ruilding
Other
BUILDING
Date
I'ad Certification
Insp.
Foundation
Pre-Gunite
Slab -I lembrane
Bond Beam
Underfloor Girders
Floor Steel
Tiedowns
Diaphrams
Seismic Bracing
halls -Panels
Frame
1,n t
Wallboards Int/Ext.
Firewalls
Other
Not Apnroved
ELECTRICAL
PLUMBING
BackflowDate
Insp.
Underground
Underfloor
_
Partial Rough
Rough Complete
Solar Rough
Water & Insulation
Main Drain
R/of/S Drain
Gas
Other
Not Approved
MECHANICAL
Dare
Underfloor S.N.
Insp.
Ducts & Insulation
Fire Dampers
Fireplace
Grease Duct & flood
One flour Shaft
Condensate Drain
Equipment Anchorage
Flues & Comb. Air
Other
Not Approved
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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON
BUILDINGAPPLICATION & PERMIT
AID.E55
�0?V 61,,.1 e- BUILDING - ELECTRICAL- PLUMBING -MECHANICAC.�4
�.JECK
PERMIT NUMBER
(�
J
I�
.S�
OWNER'S
NAME QTY. ELECTRIC PERMIT FEE
VALIDATION
-
'PHONE
'
DATE OF APPLICATION
CONTRACTOR'SOUTLETS-
NAME -II-
wlJ Ifk 1nC.: I LIGNO Pi SSblb
SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S
ADDRESS R(4
SfL. �
rrcpD)l .tl .J
4
rL ,
APPLIANCES - RESIDENTIAL 4.00
PANELS 5.00
ARCHITECT
OR
ENGINEER
' uc. NO
SIGNS 6.00
PLAN CHECK FEE P.C. N0.
SIGNS TRANS. 3.00
ARCH. OR ENO.SPECIAL
ADDRESS
CIRCUIT - 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00,
ZIP r
'
A
ADDDREDRESSSS
ff/�
2 r si. "laol d c,4- qyp`
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSE CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions Df Chapter 9
ISSUANCE DATE
(commencingwith Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full (arca and elf r.
License Class G 1 Lic. Number S65
Date � Contractor WI •� e -
BLDG.
❑
ELECT.
❑�
PLG. MECH.
❑.
BUILDING PERMIT
OWNER -BUILDER DECLARATION
I hereby affirm that I so exempt from the Contractor's License
Law for the following reason.(Sec.uires a,Businessand Professions
Code: Any city or county which requirese permit m construct, alter,
prior to its issuance, also
improve, demolish, or rep air any permit
to file
requires the applicant for such permit to file a signed Sctor's i that
he is licensed pursuant en the provisions of the Contractor's License
Division hreoof the
Law(ChapterProfessions
Business and Professions Code) or ]far lie i is exempt therefrom and
Codc) a,th Section is 00) exempt
the basis for the alleged exemption. Any violation of Section 7031.5
INFORMATION
MISC.- REFER TO ORD
VALUATION
/
/ DD
$/FT.
PERMIT ISSUANCE 6.00
ELEC. CONTR, LIC. NO.
-
-
ELEC.
TOTAL
PERMIT TO
/^1 T
/K•NSUL S[
QTY. ,PLUMBING PERMIT FEE
1
STORIES
fTYPE CONSTR.
ALTER-DRAIN-WATER(EAJ 4.00
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars,(8500)J:
'
'
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and life structure is not
BACK FLOW PROTECT. DEVICE- 2.00
OCC. GROUP
RES. UNITS
,
DRAINS -FLOOR, ROOF, AREA,COND. 4.00
intended or offered for sale (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 does such work
FIXTURES - PER TRAP 4.00
SO. FT. FLOOR. AREA
TOTAL ACREAGE
himself or through his own employees, provided that such improve-
Huntsarenotintendedorofferedforsale. If, however, rhe building
GAS - EA. SYSTEM - I INC.4 OUTLETS 4.00
wner
or improvement is sold within one year of completion, the owner-
buildere did not build or int"
builder will have the burden of proving that h
prove for purpose of sale.). -
1, as owner of the property, am exclusively contracting with
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 huilds or improves thereon, and who
.
GAS - EASYSTEM OVER 4 (EA,) LOO
BUILDING USE
RES IND CDN PB' Omer
El El El❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS'- 1 INC 5 V.B. 5.00
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
-
contracts for such projects with u contuclor(s) licensed pursuant to
the Can[ rnctor'sLicense Law.
SEWER -SANITARY -STORM EA. 200ft/6.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 4.00
re ❑ I am exempt under See. • ,B.&P.C. for (Ills
son
Dole Owner
WATER SYSTEM - 4.00
ACC. DATE
ACC. FILE NO,
WATER TREATING EQUIP. 4.00
WORKERS'COMPENSATION DECLARATION
1 hereby affirm that 1 have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
-
ZONING
ENG. SITE NO.
copy thereof (Sec.3800, Lab.CJ.
Policy No.ASY75A Company m.. Ss-, 1;x ,
-
FIRE SPRINK
y N ❑
ENERGY T 24
" Y EN�
❑ Certified copy is hereby furnished.
O Certified op )s 01 `•d wiLL( the city inspection division.
Applicant W; IVVS 2e if
MISC. - REFER TO ORD,
CERTIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE- 6.00
FLOOD ZONE
.A.L.LC.
PLG. CONTFI - LIC. NO.PLG.
TOTAL
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
v NE]
V IN F1
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars IS 100) or less.)
I certify that in the performance of the work mr which this per-
mit is issued. I stuff not employ any person in any manner so its to
become subject to the Workers' Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of lit.
eruption, you should become subject to the Workers' Compensation
provisions of the [.shot Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
BUILDING
ALTER OR ADD TO MECH. 4,00
'APPLIANCE 4.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10p00C.F.M.) •3.00
AIR HANDLING UNIT„(OVER 10MC.F.M.) 5.00
SEISMIC FEE
d -D
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this perant is issued (Sec.
3097, Civ.C.).
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UN IT (OVER 100,000 B.T.U.17.50
ELECTRIC
Lender's Name
Lender's Address
I certify that l have read this application and sure that thcubove
information is correct. [_agree to comply with all city and county,
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 3.00
PLUMBING
BOILER -COMP (3 H.P. or 100,000 B.T.U.I 4.00.
BOILER -COMP (Over 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 accrue against said City in consequence of the
PERMIT ISSUANCE. 3.00
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
grant f firs perm' : -
740
Signatu o plicant/Contractor full,
OFFICE COPY