1796 J
CITY 01' CUP ERT'INO INSPECTIOt' RECORD (Office Copy) J
V
1796 _ 20624 Cleo -.----
Pl:PdIIT 1,10. SANITARY DIST. NO. LOT NO. ADDRESS
• Repair Residence & Reroof Cal Trans 259-2232
PROJECT 01.111ER JOB SITE PHONE NO.
PERMIT ISSUED Date ELECTRICAL
Buildi.nr 5-19-82 Date Insp.
Electrical 5-19-82 Power Pole
Plumhing 5-19-82 Underground — ---
Mechanical RouFF;h Wiring _
Temp. Cas/Elect. U-a Is
Solar Ceiling
Fire Sprinkler Fixtures Int/Ext
Sign tlotors
Grounding
Ilisc. Temp. Power —
Other
FINAL. INSPECTIONS Not Approved
Date Insp.
('r.s PLUMBING
Electric r 10.ez Date Insp.
Plumbing - 3- Backflow
Mechanical Underground _
Solar Underfloor
Pool Partial Rough
Grading Rough Complete
Planning Solar rough
Fire Deft. Water & Insulation
Health Dept. Main Drain
Building -moi^ R/of/S Drain
Other Gas -
Other _
BUILDING Not Approved
Date Insp.
Pad Certification MECHANICAL
Foundation Date Insp.
Pre-Gunite Underfloor S.N.
Slab-Ilembrane Ducts & Insulation
Bond Beam Fire Dampers
Underfloor Girders Fireplace
Floor Steel Grease Duct & hood
Tiedowns One (lour Shaft
Diaphrams Condensate Drain
Seismic Bracing Equipment Anchorage
llal.ls-Panels Flues & Comb. Air
Frame Other
Lnth Not Approved
llallboards Int/Ext.
Firewalls
Other
. Not Approved
BUILDING {
ELECTRICAL
PLUMBING
MECHANICAL
MISCELLANEOUS
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY, --
"BU I LDING PROJECT I DENTIFICATI ON, PERMI Nu
-EWLOING . APPLICATION & PERMIT (�.�
:.1)ADDRESS [BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 9!
Z l ez, Zlle, - - - ---
I WNER'S
PLAN CHECK VALIDATION
G^}E
PHONE DTV. ELECTRIC PERMIT FEE
/ .
CONTRACTORS
NAME OUTLETS-SWITCHES-RECEP . 5.00/1.00
f'GAfrOC mo.•37/ O "LIGHTING FIXTURES 5.00/1.00
^( CONTRACTOR'S l
ADDRESS (/ 4SV' APPLIANCES-RESIDENTIAL 4.00
✓J'-a �✓ PNONF s'ZSS7 1?�
'PANELS 5.00 DATE OF APPLICATION
ORCNITECi SIGNS 6.00 PLAN CHECK FEE P.G N0.
- ENGINEER
LIC.NO SIGNS TRANS. 3.00 '
ADDRESS H OR ENG.- $PEDIAL CIRCUIT _ ,S.00 O PERMIT VALIDATION
41P rrEMP.METER OR POLE INS. 15.00
APPLICANT'S Y
ADDRESS c- MOTORS SEE FEE SCH.
/nL ✓.` _ n �/ 5"J % SERVICE CHANGE 10.00
o o LICENSED CONTRACTORS DECLARATION, to fit
ZO u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
H "' (commencing with Section 7000)of Division 3 of the Business and
NQG
H N 2 Professions Cd Ind ny license is in full for
� BLDG. ELECT. ' PLG.' MECH.
Z 0 _ License as Lic.Number -
@.y H Dale Gic.Nei
E a, ¢ OWNER-BUILDER DECLARATION - BUILDING PERMIT
O MISC.- --- EFER TO ORD INFORMATION
w ;n w I hereby affirm.thal I am exempt from the Contractor's License VALUATION -$/FT.
LL O a Law for the following reason.(Sec.703 1.5,Businessand Professions
- PERMIT ISSUANCE 6.00
Code:Any city Or county which requirese permit reconstruct,isissuance,
alter, a R
2 a,
improve,he applicantsh,or repair h y rmit tofile ai sign ds atom nt also ELEC.CONTR. LIQ NO: ELEC. / [ 'Id,
�0
ISI sa a requires the applicant for such permit[O lite a signed statement that TOTAL PERMIT TO
w m he is licensed pursuant to the provisions of the Contractor's License
rzQ Law(Chapter 9(commencing with Section 7000)of Division 3 of the "
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r the basis for the alleged exemption.Any violation of5ection 7031.5 STORIEW TYPE CONSTR. -
La `� by any applicant for a permit subjects the applicant to a civil penalty /fig'? '4t'
;
ofnot more than five hundred dollars($500).): ALTER-DRAIN&VENT-WATER (EA.) 4.00 G4Jy� ���� '
EI 1,as owner the property,or my employees with wages as BACK F LOW PROTECT.DEVICE' 2.00 OCC.GROUP RES.UNITS
ais
their sole compensation,
ion,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of %`
property who builds or improves thereon,and who dues such work FIXTURES-PER TRAP„ 4.00 SO.FT,FLOOR AREA TOTAL ACREAGE'
himself re through his own employees provided that such improve-
meats
mprove- - - - 'T
himself a net throng his or employeeffered for sale.provided
thatImw" suchthe building GAS-EA:SYSTEM-11NC.40UTLET$ 4.00
or improvement is sold within one,year of completion,life Owner- GAS EA.SYSTEM OVER 4(EA) 1.00
builder will have the burden of proving that h - - . BUILDING USE
e did not build or im- RES IND ePB Omer
NG
prove for purpose of sale. INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ El ❑ ❑
❑ I,as owner of p the property,em exclusively wntmc[ing with
licensed contractors to construct the project(Sea 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 improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts forsuch projects wifha contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/5.00
the Contractors License Law. TRACT NO. PARCEL NO, I
❑ I am exempt under Sec. ' ,BAP.C.for this WATEWHEATER W/VENT - • 4.00
reason
A4 19�10
Date Owner WATER SYSTEM 4.00 Ace.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent 10 self-insure, - ZONING ENG.SITE NO.
or a certificate of Workers'Compensat}'o surae or a cernfj.d _
copy there 0(yr,Wb.C.).!/ � /
Policy N I pan 7J`L7 G ///��� /kfLi
0 ❑ Certified opy is hereby fIt sl it FIRE SPRINK ENERGY T-24
Z Z. ❑ CeryL' c0 y'is Iled t ith (e t tspecb n d iskin.
Q Applicgp( xfL/ QZ[r_1M�� MISC.- REFER TO ORD. Y ❑ N YE]. .N❑ .
N CF RTI F ICAT E OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 ,FLOOD ZONE A.CU.C.
LU COMPENSATION INSURANCE, PLG.CONTR. LIC.NO. PLO.
1 (This Section need not be Completed if the peunh 4s for one TOTAL ^✓' Y❑ N❑ Y ❑ N❑
Z hundred dollars(S 100)or ImS.)
U O 1certify that in the performance of the work for which this per. CITY. MECHANICAL PERMIT FEE FEE SUMMARY
U. F mit is issued,1 shall not employ any person in any manner So as to
0 w become subject to the Workers'Compensation Laws of California.
IL Date Applicant ALTER OR ADD TO MECH. . 4.00 BUILDING
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex-
emotion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 3.00 FEE Z
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.RM.Y5.00 SEISMIC FEE 'yl�
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for wh' this permit is issued fSec. - - MICROFILM
3097,Civ.C.). - HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT 100,000'B.T.U.)7.50' '_ •/M
Lender's Address ELECTRIC
Icertify that 1.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 PLUMBING
Ordinances and state laws relating to building construction, and 8OILER-COMP(3H.P.or100,000B.T.U.) 4.00
hereby authorize representatives of this-city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We),agree`to save, Indemnify and keep harmless the City of MISC.- - REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in y way accrue against said City in consequence of the
grantE[hls permit MECH.CONT. LID.NO. MECH. -
S roTAL TOTAL
ignature of Applicant/Contractor Z Dale -
. OFFICE COPY