0654 n _ CI'T'Y OF CUPT:RT'1I10 INSPECTIOC RECORD (Office Copy)
u 1
065410500 N. DeAnza Blvd.
PEPNIT NO. SANITARY DIST. N0. LOT NO.
ADDRESS
Remodel Four Phase 255-0950
PROJECT 01-INER JOB SITE PHOIJE NO.
PERMIT ISSUED Date ELECTRICAL
Bu Ll dine 7-23-81 Date Insp.
1:1.ectrical 7-23-81 Power Pole _
PLumhinr Under ,round
tlechanical Rau ih Flirin
Temp. Gas/Elect. 11alls
Solar Ceiling,
Fire Sprinkler Fixtures Int/Ext
Sign Motors
Grounding
Hisc. Temp. Power _
Other
FINAL. INSPECTIONS Not Approved
Date Insp.
"s PLUMBING
Electric
Date Insp.
Plumbing' Backflow
!lechanical Underground
Solar Underfloor
Pool Partial Rough �
Grading Rough Complete
M•
Planning Solar Rough
Fire Dept. Water & insulation _
Health Dept. Main Drain
Duildinp R/of/S Drain
Other Gas
Other
BUILDING Not Approved
Date Insp.
Pad Certification MECHANICAL
Foundation Date Insp.
Pre-Cunite Underfloor S.M.
Slab-Membrane Ducts & Insulation
Bond Beam Fire Dampers _
Underfloor Girders Fireplace
Floor Steel Grease Duct & hood
Tiedowns One Hour Shaft_
Diaphrams Condensate Drain
Seismic Bracing EquipmenC Anchorage
halls-Panels Flues & Comb. Air
Frame Other
Lath Not Approved
Uallboards Int/Ext.
Firewalls .
Other
Not Approved
i
BUILDING
M1 V
ELECTRICAL
PLUMBING
i
MECHANICAL
MISCELLANEOUS
a - �-��
'' ,
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALI_ POINT PEN ON yCIINN
..BUILDING PROJECT IDENTIFICATION PERM NUMBER
aUILnING APPLICATION & PERMIT 0654
0 AJ BUILDING—ELECTRICAL—PLUMBING —MECHANICAL
wRER'S _ PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE I I
P.ONq IJ V
NAMERacroRs OUTLETS-SWITCHES-RECEP 5.00/1.00
LIC.No. LIGHTING FIXTURES 5.00/1.00
DDREScaORs
ADDRESS
APPLIANCES-RESIDENTIAL 4:00
CONTRA
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS SOO PLAN CHECK FEE P.C.NO.
O .
H
E NGINEEP
Llc.NO. SIGNS TRANS. 3.00
ADDREon
SS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
w 0 O LICENSED CONTRACTORS DECLARATION
a v I hereby affirm that I am licensed'undo,provisions Of Chapter 9 ISSUANCE DATE
J.
H< (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F D z Professions Code,and my license is in full force and effect. El'e O B- License Class Lie.Number
El
2 z— Date Contractor
a y E
BUILDING PERMIT
to ¢ w OWNER-BUILDER DBCLARAT'ION ' INFORMATION
w ;e I- I hereby affirm that I am exempt from the Contractor's License - MISC.— REFER TO ORD
as Law for the following reason. 7031.5,Business and Professions PERMIT ISSUANCE 8.00 _ VALUATION $/FT.
,Ay Code:Anycily orcounty which requires a permit reconstruct.alter, 11060
2 ¢ ¢0 improve,demolish,or repair any structure,prior to its issuance,also ETEC.CONTR. CIC.NO. ELEC.
i O u requires the applicant for Such permit to file a signed statement that TOTAL sd� PERMIT TO
whe is licensed pursuant to the provisions of tlse Contractor's License
HZQ Law(Chapter 9(commencing with Section 7000)ofDivision 3ofthe
i O Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE -
¢ r- $ the basis for the alleged exemption.Any violation of Sect ion 703 L5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER LEA.) 4.00
of not more than five hundred dollars($500),):
❑ 1,as owner of the property or my employees with wages as BACKFLOW 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 does such work FIXTURES-PER TRAP 4.00 SO,FT.FLOOR AREA TOTAL ACREAGE
.himself re through his own employees.provided that such ihaildve-
neehanteare not through
or employees,ffered for sale.If,however,luhcmprovg GAS-EA.SVSTEM-11NC.40UTLETS 4.00
or improvement is sold within one.year of completion,the owner- GAS-EA.SYSTEM- �( BUILDING USE
builder will have the burden of proving that he did not build or im- RES IN0 CON PB Other
prove for purpose of sale.1. INDUSTRIAL WASTE INTER. 20.00
1* I,as owner of the property,am exclusively contracting with
If censed contractors to construct rhe project(Sec.7044,Business LAWN SPRINKLERSL�W V` 00 ASSESSORS PARCEL NO.
and Professions Code: Fine Contractor's License Law does not apply
to an owner of property who builds or improves Ihereon.and who LAWN SPRINKLERS-OVER 5 IF" I 1.00
contracts far such projects with a con Tacloos)licensed purmmnt to
the Contractor's License Law. SEWER-SANITARY-STO Oft 00 TRACT NO. PARCEL NO..
❑ lam exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 4.00
reuse
Date Owner WATER SYSTEM 4.00 ACC.DATE .. ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-haere. ZONING ENG.SITE NO,
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab C.).
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRESPRINK '• ENERGY T24
❑ Certified COPY is fled with thn.
e city inspection divisio
Z
p Applicant MISC.- REFER TO ORD. Y C1 N❑ Y ❑ NEI
♦— rn
CERTIFICATEPERMIT ISSUANCE 6.00 - - :-FLOOD ZONE - A.L.U.C.
LU 1 E EXEMPTION FROM WORKERS'_ COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG.
CL a (This section need not be completed if the permit is for one - TOTAL Y-� N� Y N[]
Z) Z hundred dollar., or less.) -
0 O I certify that in the performance of the work for which this per- QTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued,1 shall not employ any person in any manner so as m '
U become subject to the Workers'Compensation Lows of California.
0 w Dam A licant BUILDING.'
a pp ALTER OR ADD TO MECH. 4.00
} rn NOTICE 'f0 APPLICANT If,after making this Certificate OI'Ex-
? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK_ �/ra3
provisions of the Labor Code, you must forthwith comply with FEE.:
C� such provisions or this permit shall be deem N revoked. AIR HANDLING UNIT(TO 10MOC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000C.FM.) 5.00 SEISMIC FEE . 77
1 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(TO 100,000 B.T.U.) 4.00 -
Lender's Name HEATING UN IT(OVER 100,000 B.T.U. .50 ELECT-RIC
Lender's Address )7 /�j Q-O
I certify that I have read this application and state that file above VENTILATION FAN (SINGLE) 3.00
. information n correct. I agree to comply with all city and county PLUMBING
ordinances and were laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,0006.T.U.) 4.00 -.. ... _...__._....... - .
hereby uuthorire representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
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 ' ny way accrue as ' sl s ' HY in conseq/Zuence of D PERMIT ISSUANCE 3.00
gr
if. f this ut MECH.CONT. LIC.NO. MECH.
TOTAL -.
v V laid 7TOTA.L_..../S -ILIU
!lignaITH,of ApplicanllConlractor Uate
OFFICE COPY