1112 C.1TY 01' CUP1iR1'I110 INSPECTIOII RECORD (Office Copy) ?
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1112 10500 N. De Anza_Blvd.
PUMT 110. SANITARY DISI. 110. L0')' NO. ADDRESS
• Remodel Four Phase 255-0900 Ext: 2037
PROJECT 01•INER JOB SITE PHONE NO.
PERMIT ISSUED Date ELECTRICAL
Ruildinr - 'Date 1.11sp.
Electrical Power Pole _
Plumbing Underground
IlccIinnica1. Rou1,h hlirin g _
Tcnp. Cns/Flect. Iiall.s
Solar Ceiling
Fire Sprinkler Fixtures Int/Ext
Sign Motors
Grounding
Hisc. Temp. Power _
Other
FINAL INSPECTIONS Not Approved _
Date Insp.
r, s PLUMBING
Electric Date Insp.
Plumbing Backflow
Mechanical Underground
Solar Underfloor
Pool Partial Rough
C,rading Rough Complete
I'lanninp Solar Rough
• Fire Dept. Water & Insulation
Health Dept. Main Drain
Building R/of/S Drain
Other Gas
Other
BUILDING Not Approved
Date Insp.
Pad Certification MECHANICAL
Foundation Date Insp.
Pre-Gunite 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 Equipment Anchorage
IIalls-Panels Flues & Comb. Air
Frame Other
Lath Not Approved
Uallboards Int/Ext.
Firewalls
Other
Not Approved
BUILDING
ELECTRICAL
PLUMBING
MECHANICAL
MISCELLANEOUS
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN-ONLY
.�i BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT PERM M1R112
�► BUILDING—s ADDRESS BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
/0500 PU, 3e /14/28- A4,1,3,
OWNER'S _ PLAN[NECK VALIDATION
NAME
QTY. ELECTRIC PERMIT FEE
CONTRACTOR3 !� d�
NRgE�sLa� OUTLETS-SWITCHES-RECEP 5.00/1.00
o (/'' N
klow LIC. o.3rJZ p OS LIGHTING FIXTURES 5.00/1.00 .
ADRRAGroRsAt PPLIANCES-RESIDENTIAL 4.00
ADDRESS
REAC r I e
22h PRONE O PANELS S.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK-7 P.L.NO.
oR SIGNS 6.00
GINEER
EN
LIC.No. SIGNS TRANS. 3.00
A ss ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPUCSS
AooREss MOTORS SEE FEE SCH.
SERVICE CHAN - 10.00
woo LICENSED CONTRACTORS DECLARATION -a Yp
II o a~a I hereby af0rn that I am licensed under provisions of Chapter 9 - ISSUANCE/DATE
HQ y (commencing with Section 7000)of Divisi 3 oBusiocss ant BLDG. ELECT. I PLG. MECH.
F 7 z s Professions C red my license is in full for fe S ❑ ❑
License lass Lic.Numbe[_ 2 198!
o N w Dal _Contractor !�AA,��y
¢ x 'IG'�ly, BUILDING PERMIT
c c w WNER-BUILDER DECLARATION INFORMATION
X ;LL m 1 hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD VALUATION S/FT.
I- u. O� Law for the following reason.(Sec:7031.5,BusinessanJ l'rofessionr PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,Met,
Q ¢a,improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. �/ •J
0, requires 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 O
Fit
Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe e-,L-f0 E
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
0
¢ r the basis for the allege)exemption.Any violation of Section STORIES TYPE CONSTR.umalty by any applicant for permit subjects the to penalty ALTER
of VENT-WATER of not more than Coo hundred dollars(my employees
❑ has owner at the property,or my employees with wages es BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
intended or
r offered
fin,will(S the work,and the structure is not
intended or offered Cor sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CONIC. 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 FIXTURES-PER TRAP 4.00 SO.FT FLOOR AREA TOTAL ACREAGE
meats are net hrough
own employees,feredfrsle.If,ed that however,
the
improve GAS-EA.SYSTEM-1 4,00
meats are not intended or Offered for sole.If,however,the building
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im RES IND CON PB Other
for purpose of sale.). I N DUSTR I A L W AST E INTER. 20.00
-❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner oI'property who builds or improves thereon,and who _ LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with it contructorfs)licensed pursuunt to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ l um exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date - Owner WATER SYSTEM 4.00 ACC.DATE ACC FILE NO.
WORKERS-COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby❑[firm that I have u certificate ofcrosent to self-Insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified
ENG.SITE N0.
copy thereof(Sec�38
— aC�JPolicy NoO Certfi cfu i ed. FIRE SPRINK ENERGY T-24
ZZCerIID 't t e ly inspection division. MISC.- REFER TO ORD.
O Applicant — - _ Y ❑ N❑ Y ❑ N❑
a: Lo PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
� CF:RTI PICCOM COMPENSATION
ION FROM WORKERS' - _
W �_ COA1PIiNSATION INSl1RANCE PLG.CONTR. LIC,N0. PLG.
CL 0 (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
Z hundred dollars IS 100)or less.)
U
01 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL P mit is issued,I shall not employ any person many manner so as to
U become subject to the Workers'Compensation.Laws of California.
IL Date Applicant ALTER OR AOD TO MECH. q,00 BUILDING
} N NOTICE 1'0 APPLICANT: If,after making this Certificate of Ex _
? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK (� 3
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 10=11F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 5.00 SEISMIC FEE
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. HEATING UNIT(TO 100,000 B.T-U.) 4.00 MICROFILM
3097,Civ.C.).
Lender's Name _ HEATING UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building Construction, and BOILER-001,11"(3H.P.or 100,0008T,U,) 4.00
hereby authorize 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.a REFER TO ORD.
Cuperti Inst Ilittle. udgments, costs and expenses which CONST,TAX
may ay a ru fast said City in co seque ee of the PERMIT ISSUANCE 3.00
gm of is pe �, MECH.CONT. LIC NO. MICH.
TOTAL
Sin are of Ap lican/C ac r U e
OFFICE COPY '