1122 CITY OF CUPERTINO INSPECTION RECORD (Office Copy)
1122
. h6h4 Clifford
PEP,CIIT NO. SANITARY DIST. 110. LOT N0. ADDRESS
Plnmhing Tershay 297-8107
PROJECT O1MR JOB SITE PHONE NO.
Date ELECTRICAL
Building. Date Insp.
Electrical Power Pole
Plumbing12-7-81 Underground
MechanicalRou h Wirin
Temp. Gas/Elect. &a s
Solar Ceiling
Fire Sprinkler Fixtures Int/Ext
Sign Motors
Grounding
Misc. Temp. Power
Other
FINAL INSPECTIONS Not Approved
Date Insp.
ras PLUBDBING
Electric
Date Insp.
Plumbing
Backflow
Mechanical Underground
Solar Underfloor
. Pool Partial Rough
Grading Rough Complete
Planning Solar Rough
Fire Dept. Water & Insulation
Health Dept. Main Drain
Building R/of/S Drain
Other Gas
Other
STRUCTURAL Not Approved
Date Insp.
Pad Certification MECHANICAL
Foundation Date Insp.
Pre-Gunite Underfloor S.M.
Slab-Ctembrane Ducts & Insulation
Bond Beam Fire Dampers
Underfloor Girders Fireplace
Floor Steel Grease Duct & Hood
Tiedowns One Hour Shaft
Diaphrams Condensate Drain
Seismic Bracing Equipment Anchorage
Walls-Panels Flues & Comb. Air
Frame Other
Lath Not Approved
Wallboards Int Ext.
Firewalls
Other
Not Approved
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI_ POINT PEN ONLY
BUILDING PROJECT IDENTIFICATIONPE MIT E
BUILDING "APPLICATION & PERMIT ��
ADDRESS
UILDING - ELECTRICAL-PLUMBING-MECHANICAL ,.
OWNS 'S - .PLAN CHECK VALIDATION
"AME ONTgpCTOR'S V. ELECTRIC PERMIT FEE
P r
C
NAME JOUTLETS-SWITCHES-RECEP 5.0011.00
-A A ACE PIAMBING LIC.N0281237 JILIGHTING FIXTURES 5.00/1.00
CONTS ADDREAcroRs PPLIANCES-RESIDENTIAL 4.00
ADORE5
X75 S0. FIRST STREETPHONE 297-810 PANELS 5.60 DATEOF APPLICATION
ARRCHITECT SIGNS 6.00 PLANCHECK FEE
ENGINEER
uc.rva, SIGNS TRANS. 3.00
ARCH.OR ENG. RCUIT PERMIT VALIDATION
ADDRESS CITY OF CUPERTIN%,P TTEMP. ETPECIAL IER OR POLE INS. 15.00
APPLICANTS - MOTOflS SEE FEE SCH.
C 1981 SERVICE CHANGE 10.00
C o LICENSED CONTRACTORS DECLARATION
a u I hereby affirm that I am licerovisions of Chapter 9 ISBUANCE DATE
y2 u. (commencin with Section 7000�O��ition 3 of the Business and
6 n 8 BLDG. ELECT. I PLG. MECH.
F y i Professions C ,,I0 license is in full for- f
z _ ,PWj.I, ❑
o vr License Class Lie.Number
Date Contrucmr
a x f BUILDING PERMIT
w OWNER-BUILDER DECLARATION INFORMATION
X ;LL,w 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION $/FT.
F LL O j Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
_ N Code:Any city or county which requiresapermil to construct,my ELEC.CONTR. LIC.NO.
at ¢o improve,demolish,or repair any structure,prior to its issuance,also ELEG.
DLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w$m he is licensed pursuant to the provisions of the Contractor's License
r z r Law(Chapter 9(commencingwith Section 7000).fDivision 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
2 r$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n; _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(8500).): '
❑ I,as owner of the property,Or my employees with wages as 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 improves thereon,and who docs such work F IXTURES-PER TRAP 4.00 SO.FT FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such im building
himselfams a net through
his or employeeffered for sale.provided
thathowevS the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4,00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM.OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- - RES IND CDN PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
C11,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to Construct the project(Sec.7044;Business LAWN SPRINKLERS-I INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Cede: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 for such projects with a contracton s)licensed purstant to -
theContractor'sLicenseLaw. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec. _ BAP.C.for this WATER HEATER W/VENT 4.00 L4 Lo
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPE.NSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate Of consent t0 scl-insure;
oor�ppryya/fcertificate of Workers Compensa/tio�n,Insuur/ranee,or a certified ZONING ENG.SITE NO.
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z Certifad y, y fdad with the city inspection division.
/p�/ /_l L MISC.- REFER TO ORD.
p RpphcantY❑ N❑ Y❑ N❑
yPERMIT ISSUANCE 6.00
� - CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL o (This section need not be Completed if,the permit is for one IOTA Y❑ N❑ Y❑, No
Z) Z hundred dollars(8100)or less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U_ F mit is issued.I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
Dy ' Date ApplicantALTER OR ADD TO MECH. 4.00 BUILDING
} H NOTICE.TO APPLICANT: If,after making this Certificate of Ex::
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
C.) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
1 hereby affum that 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. HEATING UNIT(TO 100,000 B.T.U.) 4.00 ECT
M
3097,Civ.C.l.
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
. information is street.I agree to g to b 'kith all city and county
ordinances and state laws relating to building construction, and BOILER-COMP(3'H.P.Or 100,000 B.T.U.) 4.00ICA
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. AL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequcnce of the PERMIT ISSUANCE 3.00
.. ting of this ermit MECH.CONT. LIC.NO. MECH.
ere _ TOTAL TOTAL
nature of Applicant/Contractor V
OFFICE COPY