5511 CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
FERKn, b _
.
PERMIT ISSUED DA'Z'E ELECTRICAL DATE INSP:
Nin
ctrica
Plumbing Power 'Pole
mcnanicalrun
e as ec uirin
o araW lls
Fire rin c .erei in
Sign ixtures Int/Ext
Motors
Misc. roan ing
"Te Fower
uther
FINAL INSPECTIONS DATE INSP, Not .Approve
Gas
ectric
plain PLUMBING DATE INSP.
mcnan3.ca
Molar Backflow,
Fool Underground
Urading underfloor
annu► arty u
ire t. u ete
ea t Dept. ar u
ui ing 7=� 0 WO Water '4Insulation
utneT Ffa�a
o ain
as
Other
BUILDING DATE INSP, Not Approved
Pad Certification
Foundation ELECIRICAL DATE INSP.
Pre-Gunite
Slab-Membrane Underfloor S.M.
cts nsu ation
Undertloor Girders Fire Lamers
Floor Steel 1-ireplace
ie owns Lirease muct 4 moocl
is rams a our t
eismec racin Condensate rain
Walls-Panels ui ent Anchorage
rame Flues 4 UMb. Air
T,ath Other
a oars nt xt, of rove
Firewalls
Other
Not Approved
PPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
• BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT
"°"°'"° 5511
ADDRESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
2JS`� I �oluR, -
OWNER'SPLAN CHECK VALIDATION
• .
NAME ^ �•' ' &.d. 3k.:
DTV:'", x a�ECECTRIC PERMIT ` ,FEE j
�- ko sz, PHONE ass-o7 JUN *2 5 1984
CONT ACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
7-•
FFIC 0& S7 LION°.Z95TOFj LIGHTINGFIXTURES 5.00/1.00 City,ofCupertino
/
NTRADRFaCTOR'S
AOPPLIANCES-RESIDENTIAL 4.00
CONTRA
T 7-0SO d PHONE W.41"175j, PANELS 5.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR SIGNS --, 6.00
ENGINEER'
uc.No. - SIGNS TRANS. 3.00
PRCH.OR ENG.. MIT VJtLIDATION
ADDRESS SPECIAL CIRCUIT PERMIT ,
ZIP EMP.METER OR POLE INS. 15.00
APPLICANT - ` MOTORS SEE FEE SCH.
APPLICA
a' SERVICE,CHANGE - 10.00
w o LICENSED CONTRACTORS DECLARATION h
u v 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
N a - (commencing with Section 7000)of Division 3 of the Bhsinessand a ELECT. PLG. MECH.
r n i Professions Code,and cep license-is in full force and effect.-
z o$ -, License Class_8=S_Lic.Number 3e$.$.�f0Ir
_� ❑ ❑ ❑
o y UatcS_7-$-3 Sf Contractor T
a Y 2 -a - BUILDING PERMIT ` �Pg,
Ic w Q - OWNER-BUILDER DECLARATION INFORMATION
o,a- " - - MISC.- REFER TO ORD
X 3 LL y 1 hereby affirm Thal i am exempt from the Contractor's License VALUATION - S/FT.
F u m j law Ibr the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,altar,
QQ ¢o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. / •
o u requires the applicant for such permit to File a signed slalement that TOTAL PERMIT T
w$ he is licensed pursuant to the provisions of fire Conlmctor's License
rZi Law(Chapter 9(commencing with Section 7000)of Division 3 of the I .+
a Business and Professions Code)or that he is exempt therefrom and CITY. . PLUMBING PERMIT "FEE,'
Q f o .the basis for the alleged exemption.Any violation of Section 7031.5 - STORIES TYPE CONSTR.
n ;� by any applieantfor a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than Five hundred dollars(5500).);
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE2.00 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 does such work FIXTURES-PER TRAP 4.00 SQ FT.FLOOR AREA TOTAL ACREAGE
• himself or through his awn employees,provided that such improve.
merits are not intended or offered for sale.I L however,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(EA.) 1.00 BUILDING USE E IND CON PB Other
builder will have the burden of proving!hat he did not build or im-
prove for purpose of sale.).. INDUSTRIAL WASTE INTER. 20.00 Q El 0
❑ as owner of the pr am exclusively contracting withlicensedd contractors to construct
ur
the project La 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The who
buddy o License Law does not apply
to tr owner of property who builds or improves licensed
thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s) pursrmnl to
me Contractor's License Luw. SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL NO.
- ❑ I am exempt under Sec. ,B.&P.C.I'or this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORKERS' MPIiNSATION DECLARATION WATER TREATING EQUIP. 4.00
I h*affia hove certificate of consent o a insure, ZONING ENG.SITE NO.
ar a crkers'C pensation Insurance,or a,c titled
copy (O is hereby furnis ed. FIRE SPRINK ENERGY T-24
Z Z I' f with t city in, lion division.
O �__%}� __' MISC.- REFER TO ORD. Y[] N o , y N❑
APPlicanl�. �`
~ m P ERMIT ISSUANCE' 6.00 FLOOD ZONE A.L.U.C.
CERTIFICATE OF EXEMPTION FROM WORKERS'
LL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLOTAL Y G.
CL O (This section need not he completed If the permit is for one ❑ N Y El N
=) Z hundred dollars(5100)or less) ,a4f
U O 1 certify that in the performance of the work for which Olis per DTV:- ' MECHANICAL PERMIT. FEE FEE$OI'a1MARVq k ;
LL {- mu Is issued, I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
y tgeo
Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
t.-. ? emplion,you should become subject to the Workeri 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 10MC.F.NL) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1OPM C.EM.) 5.00 SEISMIC FEE
I hereby affirm 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. MICROFILM
3097,Civ,C). HEATING UNIT ITC 100,000 B.T.U.) 4.00
Lender's Nam
Ledee H EATI NG UN IT IOV ER 100,000 B.T.U.)7.50 ELECTRIC
i s Address
Icertify that l have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and courtlyPLUMBING
ordinances and state laws relating to building com"nation,aur BOILER-C 13,11.P.ar100,000B.T.U.) 4,00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
1 above-mentioned properly 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 accrueagainst said City in consequence of the PERMIT ISSUANCE 3.00
lamming of this permit. - MECH.CONT. LIC.NO. MECH.
TOTAL
�. TOTAV: ,,
Signal IIAP or Date11
OFFICE COPY _