1034 CITY Or CUPERTINO LNSPECTIOI! RECORD (Office Copy)
1034 _ 10500 N. De An_za Blvd
PEP.MI'r PTO. SANITARY DIST. 110. LOT NO. ADDRESS
!r Remodel Interior Four Phase Systems 255-0900
PROJECT OWNER JOB SITE PHONE NO.
PERMIT ISSUED Date ELECTRICAL
Buildinv 9-11-81 Date Insp.
Electrical 9-11-51 Power Pole _
Plumbing Under ,round
Mochnnical Rough Wiring Vr�
'reap. Gas/lilect. UaLis
Solar Ceiling A
Fire Sprinkler Fixtures Int/Ext
Sign Notors
Grounding,
Misc. Temp. Power
Other
FINAL INSPECTIONS Not Approved
Date Insp.
(""s PLUMBING
Electric o O Date Insp.
Plumbing Backflow
11echanical Underground
Solar Underfloor
Pool - - Partial Roush
Crading Rough Complete
I'Lanninp Solar Rough
Fire Dept. 10 / Water & Insulation
Health Dept. *lain Drain
Suildin R/of/S Drain
Other Gas
Other
BUILDING Not Approved
Date Insp.
Pad Certification NECIIANICAL
Foundation Date Insp.
Pre-Gunite Underfloor S.M.
Slab-Hembrane Ducts & Insulation
Bond Beam Fire Dampers
Underfloor Girders Fircplac_e
Floor Steel Grease Duct & Hood
Tiedowns One (lour Shaft
Diaphrams Condensate Drain
Seismic Bracing Equipment Anchorage
Ilal.is-Vanels Flues & Comb. Air
Frame Other '
La Ch Not Approved
Uallboacds Int/Ext.
Firewalls
Other
• Not Approved •
BUILDING
`K
ELECTRICAL
r
r
1
PLUMBING
MECHANICAL
MISCELLANEOUS
42
.APPLIfANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ON
A - - MIT NUMBER
..BUILDING PROJECT IDENTIFICATION APPLICATION & PERMITRUILDING 1034
Aoa Ess Aifsal
iArA
BUILDING
- ELECTRICAL-PLUMBING-MECHANICAL
PLAN CHECK VALIDATION
NER 5
NAE OTY. ELECTRIC PERMIT FEE
FNE
oNTRAC ORs �FO SI /3 UTLETS-SWITCHES-RECEP 5.00/1.00 No
I.C.NO. LIGHTINGFIXTURES - 5.00/1.00 '
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS - 5.00 DATEOF-APPLICATION'•
ARCHITECT - 6.00 PLAN CHECK FEE P.C.NO.
OR SIGNS
ENGINEER SIGNS TRANS. 3,00
LIC.NO. PERMIT VALIDATION
ARCH.OR EN4 5.00
ADDRESS SPECIAL CIRCUIT
ZIP EMP.METER OR POLE INS. 15.00
'APPLICANT'S - MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
w o O LICENSED CONTRACTORS DECLARATION
G v s~j I hereby affirm that I OR licensed under provisions o(Chapler 9 ISSUANCE DATE
w <commene ng with Section 7000)of Division 3 of the Business anA BLDG. ELECT. zPy MECH.
Z Professions Code,and my license is in full force and effect. of -
'
{�
License Class Lc.Number 11W
o zw Date Contractor
Nf '
BUILDING PERMIT
¢ ¢ w u OWNER-BUILDER DECLARATION - INFORMATION
w3 LL H I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION $/ET.
F u o J Law for the following reason.(Sec.T03 I.S.Business and l'rofessionz PERMIT ISSUANCE 6.00 r
Code'Any city or county whlchrequiresu Perminoconslruct,alter, �d 00 C_
re Q Q 2 Improve,demolish,Or repair any structure,prior t0 Its Issuance,also ELEC.CONTE. LIC.NO. ELEQ /
O ¢ requites the applicant for such permit to file a signed statement that + TOTAL PERMIT TO
w $ he is licensed pursuant to the provisions of the Contractor's License �/-
Fii Law(Chapter 9(commencing with Section 7000)of Division 3 of the /W� /
a Business and Professions Code)or that he is exempt therefrom and GTY. PLUMBING PERMIT FEE
4 i O ST IES TYPE CONSTR.
¢ H $ the basis for the allege)exemption.Any violation of Sect ion 703 L5: /7/
d ; by any applicant for a permit subjects the applicant to a civil penalty gLTER-DRAIN&VENT-WATER IEA.) 4.00
of not more than five hundred dollars(SS00).):
EJ 1.as owner of the property,or my employees will, 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 fSec. 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;unit who does such work FIXTURES-PER TRAP 4.00 SO.FT FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA, V -1 I ETS 4,00
or improvement is sold within one year of completion, the owner- GAS-EA. T .) 1.60 BUILDING USE
builder will have the burden of proving that Ise did not build or im- REB IND CON PB CHAT
prove for purpose Of sale.). INDUS TRI LW S E N 20.00 ❑ �❑ ❑ ❑
❑ 1,as owner of the property,am ex Cursively contracting with
license) contractors 10 construct the project(Sec, 7044,Business LAWN SPRI ER IN 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 LAWNSPRINKLERS--OVFTR 5 IEA.) 1.00 -
contracts for such projects with a contracmrlsl license)pursuarV to
SEWER-SANITA EA.200ft/8.00 TRACT NO. PARCEL NO.
the Contmdnr's License Law.
❑ 1 um exempt under Sec..,B.&P.C.for this WATER HEATER W/VENT 4.00 -
reason
Dmc Owner WATER SYSTEM 4.00 ACC.DATE : ACC.FILE NO.
WORK FRS'COMPF,NSATION DECLARATION WATER TREATING EQUIP. 4.00 .
I hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,Or a certified
copy thereof(Sec.3800,Lab.0.).
Policy No. Company
Q ❑ Certified copy is hereby famished FIRE So RINK ENERGY T 24
Z Z ❑ Certified copy is fled with the city inspection division. _ MISC.• REFER TO ORD. N❑ Y ❑ No
Applicant
F -PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.C.
- CERTIFICATE OF EXEMPTION FROM WORKERS'
LU > COMPENSATION INSURANCE PLO.CONTR. LIC.NO. PLG. Y❑ N❑ Y ❑ N❑
TOTAL
4
(This section need not be completed if the permit is for one
=) Z hundred dollars IS 100)or less.) FEE SUMMARY
U O 1 certify that in the performance of the work 1'or which this per-' GTY. MECHANICAL PERMIT FEE
LL H mil is issued, shall not employ y person i an manner so us m
O W becott+e 1 rothe Workers'C ensali sof California. BUILDING /QFs�
Dalcf Applicant ALTER OR ADD TO MECH. 4.00
NOTI li T APPLICANT: If fmr making this Certificate of fix- 4 00 PLAN CHECK r)
F Z connin n,you should become subject to the Workers'Compensation APPLIANCE 7/ AN
provisions of the Labor Code, you must forthwith retmply w0h FEE
6� such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10,000CF.M.)'• 3.00 _
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 MICROFILM
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00
3097,Co.C.). p
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)7.50 ELECTRIC /. 0C)
Lender's Address
-
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 !MECHANICAL
MBING
0 information is.correct. I agree to comply with all city and county BOILER-COMPl3 H.P.or 100,000 B.T.U.) 4.00
ordinances and stale laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH.
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep hartnlass the City of MISC.- REFER TO ORD.Cupertino against liabilities,judgments, costs and expenses which NST.TAX
may i any way ac a ago t a d Ciry in consequence of the PERMIT ISSUANCE 3.00
gra m of this rm MECH.CONT. LIC.NO. MECH,
TOTAL TOTAL 0,1.31
3'Ignaturc of Applicant/Contractor
OFFICE COPY
t CENTRAL FIRE PROTECTION DISTRICT Inspection Notice
3071 DRIFTWOOD DRIVE
_. SAN JOSE, CA. 95128 Memo Form
SERVICE —SINCE 1947 408.378-4014
Occupancy / Phone
—Kldress
Memo To: Ce,)10 1740&,-
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CFD G3984 - Patersons