5854 CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
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` 1 -_- ADDRESS
-
F Cl IST �Ga`tu , ( 1�J1.
PERMIT ISSUED_. DATE ELECTRICAL DATE INSP.
Ri�3din ..
Elrical
PlumbinK Power Pole
er an_ ical...... Underground
e as ec u i iru►
o ar.: ;;:: Wates
ire:_ r er'_. F Ceiling
1 ixturere-sint/Ext
Motors
Misc Groan '
Temp ower
her Sf�- S
FINAL INSPECTIOTIS DATE INSP, ot, rove u
Gas . ,
Electric
un ink PLUMBING DATE INSP.
MecTianical
Solar Backflow
Undej iiP8alnQ. r oor
PIMM3-ng artialu —
ire.. ulete
Health Solaru
___9 Water ' insulation
- e0th r . B Min
-- o am
Gas
Other
BUILDING DATE INSP: of —rovedCertification
gos- ion ; _ - ELECTRICAL DATE INSP.
s- cite
, ran - Underfloor S.M.
eamDucts nsu anon --
-Wrtloor Ox Fire Dampers
oor tee ire ace
rease Duct 4 Hood
ee our. Shaft --
•,.- .belsme lrt fi;'I ��— 7ai ensate Drain
--" s- ane s rt — Equipment Anchorage
tram *,X 'I-lues' ues omni-Air
a Other
oar Int t: — of rove
toy'-
et rove
;a
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
9y�l BUI LDI NO PROJECT 1 DENTI FICATl PERMIT NUMBER
u. lDM3D APPLICATION & PERIIW
7807/ Q Q.4p- ' pa BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 5 8 5 4
OWNER'S PLAN CHECK VALIDATION
r NAME
�r '' 11 rr��//..�� 1 ^' '/ 9p nL
1- V�•ry 0-00"�rYOMt' NE 371 -C..7 I.1
` CONTRACTOR 5 -
NAME-, OUTLETS-SWITCHES-RECEP 5.00/7.00
Ll I-FTH'VIZ •VOL6 11C.No.ZW M3 L LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S 'pp C` VC) PPLIANCES-RESIDENTIAL 4.00
ADORES /L� P,
'Ctlp J(�yIA .T.IT+IVNIZ7CPHORE73i4- I04b PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 8.00 PLAN CHECK FEE P.C.NO.
OR
ENGINESaa
W,-y 1
lisA�• •GM LIL.NO. � 12.5 SIGNS TRANS. 3.00
ARCH OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
ADDRESS rs MOTORS SEE FEE SCH. Q//J
ADDRESS /
SERVICE CHANGE 10.00 p L�
F w o LICENSED CONTRACTORS DECLARATION d/�s)/0 /
a z F I hereby affirm[hpd L
at 1 am licensed under provisions of Chapter 9 ELCG F'd ZC - ISSUANCE DATE
H<i% (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F o z Professions CoJ�an license is in full fa'_< I ef( 'Z - -10 ❑ ❑
z o'm Liccnsc Inns Lie.Numbe
G m f_ Ua1e (n-�_Cnntrector
1,Q FT�,WNWYI
c w OWNER-BUILDF.0.DECLARATIONIN ISO
x u s- 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO
. o `� Law for the following reason.(Sec.703 1.5,Business and ProfessionspERM1T ISSUANCE 500 VALUATION SIFT.
. �
w a g Code:Any city or county which requiresa permit to construct,alter,
improve,demolish,m repair any structure,prior to Its issuance,also ELEC.CONTR. LIC.NO. ELEC.
i S O u requires the applicant for such permit to file a signed statement that TOTAL aQ / PERMIT ro
w$m he is licensed pursuanten the provisions of the )ofDivision License r s - heL+y r•, yM�m�PrH, (�IfV ^p fsllnp�(?t,n
F z a Law(Cheptrr 9(commencing with Section 7000)GfUivision3oft he y 1°,'yg
Business and Professions Code)or that he Is exempt therefrom and h t VMBIN�
the basis for the alleged exemption.Any violation ofSeclion 703 LS t1a'�k+s ns ,,In, ¢;'Y.'i; STORIES TYPE CONSTR.
i3 � by any applicant fore permit dollarsubjects $500).applicant toecivil penally ALTER-DRAINSt VENT-WATER of not more than five hundred dollars(1500).):
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.DRD-UP 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 Lew dots not apply to an owner of
properly who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
h.mself or through his own employees,provided that such Improve-
�.¢c arc not inicndeJ or offer ed for sale.if,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
,~ at nnprovemenl)s sold within one year of completion,the owner GAS•EA.SYSTEM-OV E €EY 1.00 BUILDING USE
builder will have the burden of proving that he did not build or Ise- RES IND CON PB Omar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLER q)� 47,00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law does not appiY
m an owner of property who builds or Improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
fire Con tractor's License law. SEWER-SANITARY x.00 TRACT NO. PARCEL NO.
❑ Iain exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to sell'-insure. ZONING ENG.SITE NO.
or a cerli0aate of Workers'Compensation Insurance,or a certified
copy thereof IS".3800,Lab.C.IIN
Policy No. Company 9 s 0{f' j(/E /-
O ❑ Certified copy is hereby furnished.? '-3�U�X S �� FIRE SPRINK ENERGY T-0A
Z TS Certif 'opy is fit 1 with 11 e I Y inspection dmuion.
ApplI It `• MISC.- REFER TO ORD. Y❑ N❑ Y❑ N❑
~ rn
CCRICPERMIT ISSUANCE 6.00 L FLOOD ZONE A.L.U.C.
UJ COMPE EXEMPTION FROM WORKERS'
W � COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
O' o 2 (this section need not be'comp leted if the permit is for one TOTAL 026 v❑ N❑ v❑ N❑'
DZ humdreddollan(S100)orlem) x r `4 b?�w•j"y'•yy�fE�§j,et pqary+�' ;^ a
U O - 1 certify that in the performance of the work which this per 1 L _ �DfIRN1UARRXM17 �y }7 ` i. " E
U. not is issued,1 shall not employ any person in anY manner so as l0 for
U W 14 1 r!! y 4iy;p rW y{I,Iy eT
FF become subject to the Workers Compensation Laws of California.
Data A Iicant BUILDING
M pp ALTER OR ADD TO E 4.00
} N NOTICE prion,TO APPLICANT: IL after making this Workers'
Cam
sa lix-
L.. ? Unption,you should become subject to the Workers Campemation APPLIANCE 4.00 D 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 O 0 F-11 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLINGU V owapc. M.16.00 SEISMIC FEE /
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH UCTaft 2,00
Itl09 pe7.rformance of the work for which this permit is issued(Sec HEATING UNIT( .) 4 00 MICROFILM
Lender's Name o
Lenders Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC Z0
1 certify that I have read this application and slate"hal[hC above VENTILATION FAN (SINGLE) 3.00
„!. •lo•oudimi is correct.i agree to comply with all city and county BOILER-CQMPI3 H.P.of 100,000 B.T.U.) 4.00 PLUMBING
A1C., aces and stale laws relating to building construction,and
'nercby authorize mincienla(ives of this city to enter upon the BOILER•COMP(Over 700,000 BTU)SEE FEE SCH. MECHANICAL
' �'�� above-mentioned properly for inspection purposes.
\` (We) agree to nave, 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 Mid City in consequence of the PERMIT ISSUANCE 3.00
4
fanning of(his perm' MECH.CONT. LIC.NO. MECH. i 9;}3 a .
P1 J.r at
TOTAL �k
S' , tura of Applicant/Contractor sDele s-- _ ^I44iYssry-.!���h'itilfG =
'� OFFICECOPV