6642 CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
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PERMIT ISSUED DATE 'ELECTRICAL DATE INSP.
Pin
rica
Plumbing Power Pole
Mechanicalr un
e as ec u irin
Solar Walls
Fire rin er Ceiling f- rh( P*( ^^2 N. n
T-
Z)Ign Fixtures Int/Ext
otors
Misc. Grounding
Temp ower
Uther
FINAL INSPECTIONS DATE INSP, Not rove
Gas . . Ct- rtcr_.7-TNFt ..n
Electric s r v 7- Z5- 8f-
Pl—umbing PLUMBING DATE INSP.
anica
�•�o ar Backflow
Poolun
r in r oor
Planning _ Partialu
ire t. Rouete
eat a t. bo.Lar ull
'�-Zuilding Water ' ns ation
Utfter Main Drain
oFrain
Gas
Dther
BUILDING DATE INRP. Not rove
Pad Certification
Foundation ELECTRICAL DATE INSP.
Pre-Gunite
Slab-Membrane Underfloor S.M.
Bond Beam BREF-7insulation
Underfloor Girders Pire Dampers
Floor Steel Fireplace
ie owns urease . ct 4 Hood
�a rams a our t
eisnec bracing Condensate-Drain
Walls-Panels ui ent Anchorage
rame Flues 4 Comb. r
a'— Other
1111,allboards nt ,xt. Not Approved
Firewalls
Other CI( ( , va f( tcT, /Z sioIr
eerove 7 - / / 8 `F gar32D
p " bolt. S'.ouTy o4tc � NG�
�£ fc`r, 7 / 8 ,8"�- A
BLUDING
•
ELECTRICAL
PLUMBING
MEaiANICAL
MISCELLANEOUS
4w
APPLICANT TO F<ILL,IN INFORMATION.WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
SUILDINGPROJECTJDENTIFICATION
a .
APPLICATION
DRESS 6642
/0500 /V - 0,0 wllzA -
BUILDINGELECTRICAL-PLUMBING-MECHANICAL
owry PLAN CHECK VALIDATION
974
NAME
P fjj C/�iSQ PRONE ��J t�(l�� i
--C NAME AciORs .r OUTLETS SWITCHES-RECEP 5.00/1.00
,71i--d4 J' c 'LIC.NOLIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S •,
CONTRA ys/• . /p PPLIANCES-RESIDENTIAL 4.00
d k�Ze PHONE PANELS 5.00 DATE OF APPLICATION
ogCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
SIGNS TRANS. 3.00 ' -
ADDRESS ENG, SPECIALCIRCUIT 5.00 *IT
IDTION
ZIP EMP.METER OR POLE INS. 15.00
APPLICANTS- MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 -
o ¢z
r o 0 , LICENSED CONTRACTORS DECLARATION '
¢ U U I hereby affirm that I am licensed under provisions of Chapter 9 UANCE DATE
(commencingwith Section 7000)of Division 3 of the Business and
4 w ECT. PLG. MECH.
H w Professions Code,a my license is in full force I of I. - - ❑ ❑
2
' 0. - License Cla s ^' Con Number �[
Zr Uote_�1.3Con[ractor_1�E��� .rL Lt, � •
a r��� • J , ,BUILDING'PERMIT
¢ o a< ',OWNER-BUILDER DECLARATION - ^ '„1NFORMATION.,'...
X g r I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD -
'^ t t A4UAITIC t ._,$/FT.
F LL a j Law for the following reason,(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter,-
¢ R a 0 ,improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTIL LIC.NO. TEL C. w
O¢ requites the applicant forsuchpermit to file a signed statement that TOTAL
d w m°' he is licensed pulnPERMIT TO
mot to the provisions of the Contractor's License ,
H Z Q Lliw(Chapter 9(commencing with Section 7000)of Division 3 of the /
f 4 Business and Professions Code)or that he is exempt therefrom and QTY: : ",PLUMBING PERMIT' . "FEE`
¢ D m the basis for the alleged exemption.Any violation of Section 7031.5 .' " ` ",{ STOR S TYPE CONSTR.
La by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars($500).): -
❑' 1;avowuer 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 ry
Code:The Contractor's License Law does not apply to an owner of
. , properly who builds or imptovesdhermr,and who doessuch work FIXTURES,PER TRAP 4.00 a..PT.FLOORAREA TOTALACREAGE
himself Or through his own employees,provided that such improve
ments a.,nor intended or offered for sale.Il',however,the building GAS-EA.SVSTEM-11NC.40UTLETS 4.00
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 am- -
RES INDCOM PB Other
prove for purpose of sale.). ' INDUSTRIAL WASTE INTER. 20.00 C -
❑ 1,as owner of the properly;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(EA.) .1.00
contacts I'or such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ lam exempt under Sec.-,B,&P .C.for this WATER HEATER W/VENT ' - 4,00
reason
Owner ,Dale WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
'1 hereby affirm that I have a certificate ofconsent to self-insive, - ., - ZONING
or a certificate Of Workers'Compensation Insurance,of a certified ENG.SITE NO,
copy thereof(Sec.3800,Lab.C.).��/� UA�
Policy No. C mpany
0 ❑ Certified cop sh eb ufni�y ^ FIRE SPRINK ENERGY T-24
Z 2 ❑ Certified Y f d_wii(f y' 1 Cctio wision.
Applicant L'T MISC.- REFER TO ORD. Y N❑ y ❑ ,N❑
~ PERMIT ISSUANCE - 6.00 FLOOD ZONE max+-act'
Ui ; CERTIFICATEOFEXEMPTION FROM WORKERS: -
Ill _ COMPENSATION INSURANCE PLG.CONTR. LIC.N0. PLG. '
L O (This section need not be completed If the permit is for one TOTAL YElx'21 ^Ll
Z hundred dollars($100)or less)' -
U O 1 certifythat in the performance of the work for which this er -_F,EE SU,MN)ARY d'-4 A'
LL'F- mit is issud,I shall noemploy any person in any manner so as to QTYk ,'*' ~j ,=MECHANICAL,PERMIT- - 'J FEE
U become subject to the Workers'Compensation Laws of California.
0 y Date Applicant ALTERIOR ADD TO MECH. 1 4.00 BUILDING I
} H NOTICE.TO AI'PCICANT: If,after making this Certificate of Ex- - . -
� 2 emption,you Should became subject to the Workers'Compensation APPLIANCE '4.00 PLAN CHECK
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 10,000C.F.M.) 3.00
CONSTRUCTION LEN DING AGENCY AIR HANDLING UNIT(OVER 10,000CflM.) 5.00 SEISMIC FEE
I hereby affirm that there is'a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the 3097 performance MICROFILM
C,,Ccof the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 ' '
Lender's Name
Leader's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that l have read this application find state that fire above VENTILATION FAN (SINGLE) 3.00 -
information is correct. 1 agree to comply with all city and county BOILER-COMP(3 H.P.Dr 700,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon theI 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, casts and expenses which CONST.TAX
may in any w accrue'against said City in consequence of the PERMIT ISSUANCE 3.00
granting Of s In' . MECH.CONT. LIC:NO. MECH.
TOTAL
„ TOTAL
gnalurc of Applican[jConhaclor Data
e
5 OFFICECOPV . ,