6443 Z CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
P= NO. ADDRESS
0500 /AD CGa
PERMIT ISSUED DATE tLECTRICAL DATE INSP.
caRRa
Plumbing Power Pole '
Mechanicalr un
as ec � un WITIng
Solar Walls
F3-re Sprinkler Ceiling
ign Fixtures Int/Ext
Fut—ors
Misc. Grounding
e ower
Uther
FINAL INSPECTIONS DATE INSP. Not Approved
Gas
Electric
Plu–mbinR PLUMBING DATE INSP.
mechanical
•oar Backflow
Poo r im
GradinR oor
annin Partial
ou
ire t. u ete
ea t t. Solar u
i in ater ' Insulation
er Main Drain
o ain
Gas
.Other
BUILDING DATE INS, P. Not rove
Pad Certification
Foundation ELECTRICAL DATE INSP.
Pre-Gunite
Slab-Nbmbrane Underfloor S.M.
bond am Ducts & Insuiation
Undertloor G:Lrders Fire Dampers
Floor Steel Fireplace
ie owns urease ct & Hood
i.a rams a our Shaft
eismec braSing Condensate Drain
aT�I�s- �aneTs uiAnchorage
Frame Tlues r
a� t er i3l�oar nt t. of Approved
Firewalls
Other
Net rove
BUILDING
ELECTRICAL
PLUMBING
maiAMM
MISCELLANEOUS
/ APPLICANT TO FILL IN INFORM&JION WITHIN RED LINES - USE BA DINT PEN ONLY
PERMIT NUMBER
' BUILDING PROJECT IDENTIFICA710 APPLICATION & PERMIT
-y.,• ADDRESS - 6443
ADonsss
/OSSOO Al- Qt AA1Z/1 X1 VP BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S - i .. - PLAN CHECK VALIDATION
•y, NAME. Zss-0000 a.�^';' �1 §^4 .�.4f ..
// 'A'7ECECTRIC^P,ERMIT a - I Yf`FEE',.
�'0✓/Z'!2/�nl� Sy.I TMS PHONE L�YT'TSL 7 il:m•
NAMERAcroq's UTLETS-SWITCHES-RECEP 5.00/100
LIC.NO, LIGHTING FIXTURES 5.00/1.00 '
COf,DNTRASSc7oga
DREPPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.No. � - SIGNS TRANS. 3.00
ARCH.OR ENG. - PEfiJ.11T V LIO TION
'ADDRESS SPECIALCIRCUIT 5.00
ZIP EMP.METER OR POLE INS. 15.00 �J
APPLICANTS MOTORS SEE FEE SCH. /
ADDRESS
SERVICE CHANGE 10.00
m o o , LICENSED CONTRACTORS DECLARATION e
<u w 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE GATE
EQ vAi (commencing with Section 7000)of Division 3 of the Business and DG. ELECT. PLG. MECH.
F m z Prolcssmas Code,and on,license is in full farce and effect. ❑ ❑ ❑
,e 0.- License Class Lie.Number -
D r w Datc Contractor
Fa m f BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION '� "`
¢w u MISC.- REFER TO ORD INFORNIATIUNS '
w•;LL I- I hereby affirm that I am exempt from the Contractor's License S/FT.
FUN¢ Law lin, following reason(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter,
¢'Q a o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
i w m G, requires the applicant for such permit to lila a signed statement that TOTAL, �, p TO
he is licensed pursuant to the provisions of the Contractor's License
F z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe '
Business and Professions Code)or that he is exempt therefrom and CITY:-' PLUMBING PERMIT FEE-
¢ r$ the basis for the alleged exemption.Any violation of Section 70315 ^ In TYPE CONSTR.
i+3 _ by any applicant for a permit subjects the applicant loa civil penally
ofnot mora than five hundred dollars(55001.): ALTER-DRAIN&VENT-WATER (EA.) 4:00
❑ 1,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
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who Joe,such work FIXTURES,PER TRAP 4,00 50,FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve'
memsarenot intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4,00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA) 100 BUILDING USE
builder will have the burden of proving that he did not build nr im- . . .
RES IND CON PB Ornar
Prove 1. purpose of[lief. INDUSTRIAL WASTE INTER. 20.00 ❑ �El 0 1 ,
❑ d as owner of the properly,he exclusively contracting with
licensed contractors to ce Contractor's
the project Lo 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 - ASSESSORS PARCEL NO.
and Professions Coope The who
tractor's License Law does not apply '
to tr owner of properly who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5(EAJ 7,00
the Cads for st¢Ir projects with a conlradorf s)licensed pursuant m
the Contractor's license law. SEWER-SANITARY-STORM EA.,200ft/8.00 TRACT NO. PARCEL NO.
❑ Iumexemplunder Sec. ,B.&PC.forthis WATER HEATER WIVENT • 4.00
reason
/ Owner Date 6 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 ofconsent ID selfinsure. ZONING ENG.SITE NO.
or 4 certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3000,Lab.C.). -
PoIIry No. Comp4ny
O ❑ Certified copy is hereby furnished FIRES RINKENERGY T.24
. Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
N
O Applicant N[] Y �
Cc W CERTIFICATE 01'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 LO O Z E
W > COAIPFNSATION.INSURANCE PLG.CONTE. LIC.NO. PLG,
d O I'fhis section need not-he completed if the permit is for one TOTAL Y❑ Yam
0 2 hundred'dollar,IS 100)or less.) -
U O I certify fiat in the performance of lire work'for which this per QTY`: MECHANICAL PERMIT FEE FEE SUMNIARV:
kfL F mil is issued,I shall not employ any person in any manner so as to
V become subject to the Workers'Compereation Laws of California .
U to Daft Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} so NO"I'ICE TO APPLICANT: If,after making this Certificate of Ex-
F 2 emplion,you should become subject no the Workers'Compensation APPLIANCE 4.00 PLAN CHECK r1
provisions of the Labor Code, you must forthwith comply with FEE CX/ ZZ
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 3.00
CONSTR UCI[ON LENDING AGENCY - AIR HANDLING UNIT(OVER 10=11F.M.) 5.00 SEISMIC FEE ..�
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which thispermil is issued(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name -
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify fhal l have read thisapplication and slate that theabove 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-COMPI3 H.P.or 100,000B.T.U.) 4.00
hereby authorize represenlutives of this.'iity to enter upon the - BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly 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 PERMIT ISSUANCE 3.00 CONST:TAX
may in any way accrue against said City in consequence of the
gra g f this permit. MECH.CONT. LIC.NO., MECH,
\. � La•'A , -512D/0/ rorAL TOTAL
Signature of Applicant/Contractor Date
OFFICECOPY