1139 r~fy ~ ti CITY Or CUPEP.TINO INSPECTION RECORD (Office Copy)
1139 10700 N. De Anza Blvd.
PERMIT 110. SANITARY DIST. NO. LOT NO. ADDRESS
Remodel f32- rJn /_ /� , Four Phase
LyL+.rn� �1cs�9s� f��(.� 255-0900 Ext: 2037
PROJECT 014NER JOB SITE PHONE NO.
Date ELECTRICAL
Building ' ' Date Insp.
Electrical Power Pole
PlumbingUnderground
Mechanical Rough Wiring
Temp. Gas/Elect. Fulls
Solar Ceiling
Fire Sprinkler Fixtures Int/Ext
Sign Motors
Grounding
Misc. Temp. Power
Other
FINAL INSPECTIONS Not Approved
Date Insp.
Ga s
Electric PLUMBING
Plumbing Date Insp.
Mechanical Backflow
Underground
Solar Underfloor
Pool Partial Rough
. Grading Rough Complete
Planning Solar Rough
Fire Dept. Water & Insulation
Health Dept. 'Iain Drain
Building R/of/S Drain
Other Gas
Other
STRUCTURAL 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
Ti.edowns One Hour Shaft
Diaphrams Condensate Drain
Seismic Bracing Equipment Anchorage
Flalls-Panels Flues & Comb. Air
Frame / ��3 �/ Other
Lath Not Approved
Wallboards Int/Ext.
Firewalls
Other
Not Approved
BUILDING
ELECTRICAL
PLUMBING
PIECHANICAL
MISCELLANEOUS
.APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENT]FICATION PERMIT NUMBER BUILDINGAPPLICATION $ PERMIT
�
1139
Ao REss
DE BUILDING-ELECTRICAL-PLUMBING -MECHANICAL 113 9
WNER'S PLAN-CHECK VALIDATION
N /J OTY. ELECTRIC PERMIT FEE -
J
PHON
CONTRACTORSA�w
NAME Axr a / OUTLETS-SWITCHES-RECEP 5.00/1.00
LIC.NO. - LIGHTING FIXTURES - 5.00/1.00
ADDRESS
ADDRESS PPLIANCES-'RESIDENTIAL 4,00
PHONE PANELS 5.00 DATE OF APPLICATION
ORRF
CHITECT SIGNS 6.00 PLAN CHECK EE P.C.NO.
ENGINEER
LIC,NO. SIGNS TRANS. 3.00
ARC H.Oss EENO SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRZIP EMP.METER OR POLE INS. 15.00
APPLICANT- - MOTORS SEE FEE SCH.
/vo
ADDRESS
- SERVICE CHANGE 10.00 0.00
woo LICENSED CONTRACTORS DECLARATION
< u uU I hereby affirm that I am licensed under provisions of Chapter 9 CiV OE CUPERTINO ISSUANCE GATE
v,G e- (commencing with Section 70001 of Division 3 of the Business and SLOG. ELECT. PLG. MECH.
F w i Professions Code,and my license is in full force and effect. ❑ ❑
o i u, o License Class Lic.Number ❑
OCT
/ 1
Date Contractor _
a Y f BUILDING PERMIT
o a 'OWNER-BUILDER DECLARATION INFORMATION
w ;a. H I hereby affirm that I am exempt from the Contractor's License MISC.- EFER TO ORD
u O j Law for the Following reason.(Sec.7031.5,Business and Proe.mas VALUATION
H - g PERMIT ISSUANC - 6.00
Code:Any cityorcounty which re4uiresa permit toconstruct,alter, ] OOO
Q p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
at
wD¢ retluires the applicant for such permit to file a Signed statement that TOTAL PERMIT TO
m a he is licensed pursuant to the provisions of the Contractor's License
r z i Law(Chapter 9(commencingwith Section 700m)of Division 3 of the
a Business and Prepositions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any ore than five
a permit subjects the 00.);applicant too civil penalty
Of not more than five permit
dubjects tileap li ALTER-DRAIN& VENT-WATER (EA.) 4,00 -
❑ I,os owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
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
property who builds or improves thereon,and who dues such work FIXTURES-PER TRAP 4.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided weld such improve-
ments are not intended or offered for sale.prov,however,ided
that such
pro pg GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
Or improvement is sold within one year oi'completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 euILOIN uSE
builder will have the burden of proving that he did not build or im. o RES IND 00 PB Orher.
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
`A 1,as owner of the property,am exclusively contracting with El ❑ ❑
licensed contractors to construct the project(Sec. 7044,lousiness 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 proprrty who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts for 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.
❑ Iam exemp under5 ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date fswwner WATER SYSTEM I 4.00 ACC.DATE ACC.FILE No.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I herebyaffirm that I have a certificate of consent to selGinsure' ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified Copy Is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is Bled with tlm city inspection division. MISC.- REFER TO ORD.
O Applicant Y N❑ Y ❑. N❑
s'� y CERTIFICATE OF 17XEMII PION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE AL.u.c.
W > COMPENSATION INSURANCE PLG.CONTR. .LIC.NO. PLG.
Q.Z (This section need not he completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
hundred dollars 1$100)or lessI
U O 1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not cmploy any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
Lid Datc Applicant ALTER OR ADD TO MECH. 4.00 BUILDING 3?
} rn NOTICE TO APPLICANT: If,after making this Certificate of Ex
I. Z emption,you should become subject to the Workers'Compensation - APPLIANCE 4.00 PLAN CHECK.
provisions of the Labor Code, you must forthwith comply with �3
C.) such provisions or this'pernit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00 FEE o2
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE SD
I hereby affirm Orat there is a Construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
N0MICROFILM
7 performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATI NG UN IT(OVER 100,000 B.T.U.P.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information n correct I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 - PLUMBING
oNinances and state laws ote to c to building Construction.C. and
hereby authorize representatives of this.city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH. 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, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX '
may in any way xcc a against Said'City in CORS, ence of the
l grp m of this perp MECH.CONT. LIC.NO. MECH. • '
TOTAL TOTAL 63 sa
ignalure of Applicant/Contractor ,Da Is
OFFICE COPY