15361536
PFRMT i ?0.
CITY OF CUPERTINO Ii:SPECTION RECORD (office Cony) kx
SAiiITAP`I DIST. NO. LOT N.C.
Plumbing
PROJECT_
Burzio
Date
Building
Electrical
Plumbing
lechanical
Temp. Gas /elect.
Fire SDrinkler
Sign
?disc.
FINAL I17SPECTIONS
Date Insp.
Electric
Plumbing
:techani cal
•Grading
Plannin^
mire Dent.
health Dept.
Building
Other
STRUCTURAL
Date Insp.
Pad Certification
Foundation
Pre - Gunite
Slab- `tembrane
Bond Beam
Underfloor Girders
Floor Steel
Ti edoems
Diaphrams
Seismic Rracin
Halls- Panels
Frame
Lath
[lall.boards Int /Est.
Firewalls
Other
Not Approved
22253 DeAnza Gir
ADDRESS
257 -8390
0WNER JOB SITE PHO;JF V0.
ELECTRICAL
Date Insp.
Power Pole
Underground
P.ou 4liring
vial s
Ceiling
Fixtures Int /Est
i °fotors
Grounding
Temp. Poorer
Other
Not Approved
PLUMBING
Date Insp.
Backflou
Underground
Underfloor
Partial P.ourh
Rough Complete
Solar Rough
Water & Insulation
:fain Drain
R /of /S Drain.
Gas
Other
Not :Approved
`!ECF -M IC AL
Date Insp.
Underfloor S.
Ducts & Insulation
Fire Dampers
Fireolace
Grease Duct & Mood
One Hour Shaft
Condensate Drain
Equipment Anchorage
Flues & Comb. Air
Other
.Not Approved
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY zte�l
BUILDING PROJECT IDENTIFICATION
APPLICATION &' PERM IT
BUILDING— ELECTRICAL — PLUMBING— MECHANICAL
PERM N
1536
euuolxc
aooRESs
ry R'
- -
-
PLAN CHECK VALIDATION
F E n
1
QTY.
ELECTRIC PERMIT
FEE
DATE OF APPLICATION.
CONTR TOR'5
NAME (�
OUTLETS - SWITCHES - RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
oNTRACTOR's
ADDRESS
1
PPLIANCES - RESIDENTIAL 4.00
PANELS 5.00
ARCHITECT
OR
ENGINEER
• Llc. xo.
SIGNS - 6.00
PLAN CHECK FEE P.C. NO.
-lam I '
SIGNS TRANS. 3.00
ARCH. OR ADDRESS ENG.
ZIP
SPECIAL CIRCUIT 5.0Q
PERMIT VALIDATION
TEMP. METER OR POLE INS. - 15.00
A -
ADDRESS DDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
/ C�
a
/
LICENSED CONTRACTORS DECLARATION
My OF CUPERTINO
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Cpl license is in full f
License CIasS -- - Lic. Numtg2
Date Con[mctor
ISSUANCE DATE
MAR 0 1 loo')
BLDG. ELECT.
❑ ❑
PLG. MECH.
❑
OWNER- BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following mason. (Sec. 7031.5, Business and Professions
Code: Any city or county which requi —a permit to construct, alteq
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9(commencing with Section 7000) of Division 3 ofthe
Business and Professions Code) or that lie is exempt therefrom and
BUILDING PERMIT
INFORMATION
M ISC.— EFER TO ORD
VALUATION
$ /FT.
PERMIT ISSUANCE 6.00
ELEC. CONTR. LID, N0.
ELEC.
TOTAL
PERMIT TO -
-
P�U
GTV.
PLUMBING PERMIT
FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
I
by any applicant for a permit subjects the applicant to a civil penalty
of not mare than five hundred dollars (S500).):
ALTER-DRAIN & VENT-WATER MA.) 4,00
❑ I, as owner of the properly, or my employees with wages as
their sole compensation, will do the work, and the structure Is not
BACK FLOW PROTECT. DEVICE 2.00
Occ. GROUP
RES. UNITS
.
DRAINS- FLOOR, ROOF, AR EA, COND. 4.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve -,
m re
ents a not intended or offered for sale, If, however, the building
FIXTURES - PER TRAP 4.00
$O. FT. FLOOR AREA
TOTAL ACREAGE
-
GAS- EA.SYSTEM -1 1NC.40UTLETS 4:00
or improvement is sold within one year of completion, one owner-
builder will have the burden of proving that h e did not build or an-
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
. .
GAS - EA SYSTEM -OVER 4 (EA:) 100
BUILDING USE
RES IN CON Pe osner
❑ ❑ ❑ ❑ ❑
INDUSTRIALWASTE INTER. 20.00
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
ILAWN SPRINKLERS - OVER 5 (EA.) 1,00
ASSESSORSpARCEL NO.
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon. and who
contracts for such projects with a contractors) licensed pursuant to
the Contractor's License Law,
SEWER - SANITARY -STORM EA. 200ft /8.00
yTRACT NO.
PARCEL NO.
❑ I am exempt under Sec. ,B. &P.C. for cis
reason
WATER HEATER WIVENT 4.00
Ll
Date - Owner
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORKERS'COAIPIINSATION DECLARATION
-
I hereby affirm that I have a certificate of consent to sell' - insure.
or a certificate of Workers' Compensation Insurance, Or a certified
ZONING
ENG. SITE N0. .
❑ Certified copy is Hereby furnished.
[Certified -copy is file the city ih action Division,
�Ajjpbcant
FIRE SPRINK
Y N
❑ ❑
ENERGY T -24
V N
❑ ❑
MISC:- REFER TO ORD.
CERTIFICATE OFEXEMPTION FROM WO
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.u.C.
PLO. CONTR UC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
Y ❑ N❑
I Y ❑v N❑
hundred dollars IS 100) or less.)
I certify that in the performance of the work for which this per-
HILL is issued, I shall not employ any person in any manner so as to
QTY.
MECHANICAL PERMIT
FEE
FEE SUMMARY
BUILDING
-
become subject to the Workers' Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after racking this Certificate of Ex-
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4:00
PLAN CHECK
emption, you should become subject to the Worker[ Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked
FEE
AIR HANDLING UNIT (TO 10=C.F.M.) 3.00
AIR HANDLING UNIT(OVER 1000C.EM.) 5.00
SEISMIC FEE
. CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
HEATING UNIT (TO 100,000 B.T.U.) 4,00
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
Lender's Name
Lender's Address
I certify that 1 have read this application and slate that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 3.00
-
PLUMBING
BOILER - COMP (3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL -
hereby authorize representatives of this city 10 enter upon the
above- mentioned property for inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX
(We) agree to save, indemnify and keep harmless the City Of
Cupertino against liabilities, judgments, casts and expenses which
may in any way accrue against said City in consequence of the
PERMIT ISSUANCE 3.00
MECH. CONT. LIC. NO. -,-
MECH.
og fthi errant.
Al
.'
TOTAL
TOTAL
'Io r f c nl .RuaCt Or' Date
OFFICE COPY