3133 ' COPY OF CUPEPTINO IIISPFCTIOt! RECORD (Office Copy)
3133 10500 N. De Anza Blvd.
PERMIT N0. SANITARY DIST. N0. LOT N0. ADD RI(SS
Interior Remodel Four Phase
PROJECT 01•iNER JOB SITE PIIO14E NO.
PERMIT ISSUED Date ELECTRICAL
BuLidi.nc _ Z-16- Date Insp.
Iaectrieal -7--Tg---UT Power Pole
lambing Undc_r ----
Mechnni.cal T-T '3- RouF%h Miring --__
Temp. Gas/Elect. halls _
Solar Ceiling
Fire S12rinkler Fixtures int/Ext _
Si ,n llotors
Grounding
Misc. Temp. Pooer _
Other
FLNAL INSPECTIONS NoL 'ApVraved _
Date Insp.
r,:s
PLUPfBING
Ei.ectr _c Date Insp.
Plumbing Backflow _
tIechanical Underground
Solar Underfloor _
Ponl Partial. Rough
•
Gra(ling Rough Complete
Planning Solar P.ou ,h _
Fire Dept. Water & Insulation _
Health Dept. 'lain Drain
Building R/of/S Drain
Other Gas _
Other
BUILDING Not Approved
Date Insp.
Cad 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 (lour Shaft _
D.i.aphrams Condensate Drain _
Seismic Bracing Equipment Anchorage _
Halls-Panels F] ue.s & Comb. Air
Frame Other
Lnth Not Approved
llallboards Int/1'.xt .
Firewalls
. Other
Not Approved
BUILDING
•
ELECTRICAL
PLUMBING
MECHANICAL
it
MISCELLANEOUS
i
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIF I CATION P M BER
' BDILDING APPLICATION & PERMIT 133
ADDRESS
/0500 /I/ ?)EANLA BLVD. BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME QTY, ELECTRIC PERMIT FEE
. Four-PH se 6X5`E PRONE,2Ss- 00 �j�-3
NOMERADTORs �'f OUTLETS-SWITCHES-RECEP 5.00/1,00 fl
O VVFe uc.ND. ,`„Z LIGHTING FIXTURES 5.00/1.00 `.S
72-
ADDRESS ons PPLIANCES-RESIDENTIAL 4.00
CONTRACT
PRONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 600 PLAN CHECK FEE P.C.NO.
.
OR
ENGINEER
I LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
'ADDRESS SPECIALCIRCUIT 5.00
ZIP EMP:METER OR POLE INS. 15.00
APPucnnrs MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 -
0 0 o LICENSED CONTRACTORS DECLARATION
< W I hereby affum that I am licensed under provisions of Chapter 9 - ISSUANCE DATE
N Q y (commencing with Section 7000)Of Division 3 of the Business and - BLDG. ELECT. PLG. MECH.
H N z Professions Code,and my license is in full force and effect ElEl ❑
z O m - License Class Lic.Number
H D Date Contractor
a , s I BUILDING PERMIT
r[ Ica OWNER-BUILDER DECLARATION
0 u, u INFORMATION
i`xR ;LL L. I hereby affirm that I am exempt from the Contractor's License MISC:- REFER TO ORD
m VALUATION $/FT.
F .. D a Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
3v'02 Code:Any cityor Omoty which requires a permit to construct,alter,
QLD
Q a Q D
n Improve,demolish,or repair any structure,prior to its Issuance,also ELEC.CONTE. LIC.NO. ELE
a O requires.the applicant for such permit to file a signed statement that TDC.
TAL PERMIT TO
Tu$ he is licensed 9(copursuant to the provisions of the Cantrivisios 3 iodic
z4 Law(Chapterad
Codeng with Section is 00)exempt
n3 ofthe
Q Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
the balls for the alleged exemption.subjects
Any violation oto action malty STO IES TYPE CONSTR.
by any applicant fora permit subjects theapplicam toacivil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars($500).1:
❑ I,as owner of the Property,or my employees with 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 (Sec. 7044, Business and professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 �r�
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 SO.FT FLOOR AREA TOTAL ACREAGE
himself re through his own employees,fors Provided that such improve.
ments rmello Through
ot or offered provided
that suhebuilding ' GAS-EA,SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the Owner-
builder USE
will have the burden of proving that he did not build or Int- . . .
RES IND CON PB Omer
prove for purpose of Ole.). 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 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 of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a ecu ractor(sl licensed purstunt to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt muter Sec. B. P.C,for this
reason - WATER HEATER W/VENT 4.00
Date owner ' WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'CONPENSATION DECLARATION WATER TREATING EQUIP. 4.00 �-
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.C.). '
Policy No.-Company-
0
o. CompanyO ❑ Certified cop)'is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC- REFER TO ORD.
O
Applicant V V N❑
XH PERMIT ISSUANCE 6.00 FLOOD ZONE
� CERTIFICATE PE EXEMPTION PROM WORKERS'
W >_ COMPENSATION INSURANCE PLG.CONTR. u0.NO. PLG. �-t
CL o (This section need nal be completed if the permit is for one TOTAL Y❑ ❑
� Z hundred dollars(S100)or hiss.)
U O I certify that in the performance of theworkfor which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
O become subject to the Workers'Compensation Laws of California.
0 w Date Applicant BUILDING p/
a p ALTER OR ADD TO MECH. 4.00
} N NOTICE '10 APPLICANT': If,atter making this Certlficam of Ex-
♦- ? emption,you should become subject to the Workers'Conipensmion APPLIANCE 4.00 PLAN CHECK
Provisions of the Cabo, Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=1C.F.M.) 5.00 SEISMIC FEE �Q
I hereby affirm that there is a consiructmn lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,ON C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 -
Leader's Name - �'J
Lenders Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC .:�:3
I certify that I have read this application and state that the shove VENTILATION FAN (SINGLE) 3.00
. information n correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construct inn, my BOILER-COMP(3 H.P.Or 100,0008.T.U,) 4.00
hewhy authorize representatives of this city to enter upon-the BOILER-COMP (Over 100,000 BTUI SEE FEE SCM. MECHANICAL Gf0
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 whichCONST.TAX
I� PERMIT ISSUANCE 3.001J
may in any way accrue against said City in consequence of theL--
granting of this Permit MECH,CONT, LIC,N0. MECH.
��.,� t a/8/83 oTAL 7 a.a TOTAL /� 7
�i8a hi rc Applicant/Contractor
OFFICE COPY is