06441 01 CITY Or CUPlIIMNO INSPF.GTIOL' RECORD (Office Copy)
' 0644 _ 22306 DeAnza Circle
PEMIT NO. - SANITARY DIST. NO. - LOT NO. - ADDRISSS
0- Reroof John Parham 257-7529
a 1
PROJECT 01-DIER JOB SITE PHONE NO.
PERMIT ISSUED Data II ELECTRICAL
Butldtnr,
Electrical
Plumhin,r,
Mechanical
Temp. Gas/Elect.
Solar
Fire Sprinkler
Sign
Hisc.
FINAL. INSPECTIONS
BUILDING
Date Insp.
Pad Certification
Foundation
Pre-Gunite
Slab-ILembrane
Bond Beam
Underfloor Girders
Floor Steel
Tiedowns
Diaphrams
Seismic Bracing
halls -Panels
Frame
lath
Uallboards Int/F.xt.
Firewalls .
Other
Not A? roved
Date f Insp.
Rou ;h Wiring
I I a I --
Ceiling
Fixtures Int/Ext
Motors
Grounding
Temp. Power '
Other
Not ApVroved
PLUMBING
Date
Backflow
Insp.
Underground
Underfloor
Partial Rough
Rough Complete
Solar Rough
Water & Insulation
Main Drain
R/of/S Drain
Gas .
Other
Not Approved
MECHANICAL
Date Insp.
Underfloor S.M.
Ducts & Insulation _
Fire Dampers
Fireplace
Grease Duct & hood _
One flour Shaft
Condensate Drain
Equipment Anchorage
Flues & Comb. Air
Other
(APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN OALR
INA LDI NG PROJECT I DENTI FICATION
-- _
_ _APPLICATIQN&PERMIT0644-
BUILDING ELECTRICAL=PLUMBING-MECHANICAL
P Mrt NumBEfl
BDILDING - - --Ilf-
ADDRE3bb • ¢�A1 1%I
OWNER'S ,- -„�
NAME _. ._.�_�-
- ""
.....__.�..-_ .. _
QTY. "" FEE
PLAN CHECK VALIDATION
'
10 1 _
,.
DATE OF APPLICATION
PLAN CHECK FEE P.C. NO.
.,: .: ._... ..
-
CONTRACTOR'S5.00/1,00 .... .,,-„---,,,
AME ^ •••-•-•-... .._ ._.......-
to LIC. LIC. NO r/Jf//
., „•-
._. _.. TL'E9''5,,;,SWITCHES-AECEP _,_ ....
LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S .. - ..-... -..-�_�.-....`
AODREss/ '-"' � �
I'lam SJ rn�� /'%V•` PHOry ���jCJ
�1�/n/y�y" /n]�,
ARCHITECT�V/"' I �r _
ENGINEER
""" PP•LhANCfS;'RESIDENTIAL - �• 4.00- .--
PANELS 5.00
......;: SIGNS-.:._...-.__.... -. 6.0 ,. _. _..
SIGNS TRANS. 3.00-
ARDH,ORENG. ..-_... ,:..,_..
. _. ....., . ......
ADDRESS """',-""'""'='-"'
ZIP' �
- - _. ., ,55.00
,_ � ..
SPECIAL CIRCUIT-
_ PERMIT VALIDATION
.. ._ ... ...
EMP. METER OR POLE INS. - - 15.00
APPLICANTS
ADDRESS
MOTORS_SEE FEE SCH.
SERVICE -CHANGE 10.00
LICENSED COI'yZR11qOR$-)ECLARATION
Ihereby affirm that I am licensed under prov11 isions of Ch,ipter 9'
ISSUANCE DATE
(Commencing wills $edion 7000) of Division 3 of the Business and
Profen enciCode,, my license is in full fort Pod •e B
License CIS _._-._ Ie is inf '.._•._
.
Date - '- COnlraCle�'
BLDG.
ELECT
�...
PLC.
_
MECH.
..0 _... _...,-...__..
•.' .- -.
1.__. _....
'
BUILDING PERMIT
OWNER.B1llLD4RD1iCLA -----•---
I hereby affirm that ham exempt from the Contractor's
Law for the following Poison. (Sec. 7031.5, Businessand Professions
Code: Any city or county which requiresage�millor onstruct,alter,
. ._.... _
improve, demolish, or repay any 51Nelure, poor to its issuance, a(so�
INFORMATION..
"
----_. ....
EF.EA'TO ORD
VALUATION
/l 0 .
boo
1q f
x� /: � '
PERMIT ISSUANCE 6.00
'EL_ CONM.' - "'__;- LIC:+•10:_^ - ._..,
'E'LEC.""-'_ '-
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractors License
Law (Chapter 9(commenciRg wNb$nglloa70Wlof6svisiOn3 ofllt
Business and Professions C I,71or-Of Fe'u c'xcTinjrhlfeYEfrbffi`u
the basis for the alleged exemption. Any violation of Section 7031.5
'
TOTAL
PERMIT TO
1��Q.l�OfT QHS,
QTY:;'--•I!EUMBTNG�P6RMIT. FEE
"
STORIES
TirECONSTR.
by any applicant for a permit subjects the applicant to a Civil penalty
of not more than five hundred dollars ($500).1:
ALTER-QRAIN.¢VENT-WATER (EA.)4.00
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions
BACK F LOW:PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, COND. 4.00
Code: The Contractor's LiceTise LAW-db&Tdrgrp .ttlTt9wnertOP
property who builds or improves thereon, and who does such work
; "
FIXTURES - PER TRAP "" - 4.00
-- - -
--
SO, FT. FLOORAREA
TOTAL ACREAGE
himself or through his own employees, provided that such improve.
• ments are not intended or pf[seed,J9rdAb, u'.hnwa;rlhe building•
or improvement is sold within on€'yBar'osccenlpletiom-ttW7, er
builder will have the burden of proving that he did not build orim-
prove for purpose ofole.).
Cl I, as owner of the properly, -am nlH:IµSsw{y,c+>MraWinl}with-
licensed contractors to construct the project(Sec. 7044;'B6smess
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon. and who
GAS-EA.SYS-11NC.40UTLETS 4.00
- GA,5 -'EA. SYST fl 4 (EA.) 1.00 -
BUILDING USE
RES IND CON PB Other
l -I
❑ ❑ .. ❑ ❑ ., I, -I
INDUSTRIA TEI 20.00
"'- LAWN SPRINK S I I N G 5 S.00
ILAWN SPRINKLERS- EA.) 1.00
�. ASSESSOR SPARCELNO.
_.
contracts for such projects woITAd idnlr3cf(1rfC1'IttYTSRf(RM1TrttC:19;
the Contractor's License Law. -
❑ 1 am exempt under Sea BAP.C. for this
reason
._.,
SEWER-SANIT RM. EA. 200ft/6.00 .-.,._
TRACT NO.
PARCEL NO.
WATER HEATER MOANT 4.00
Ume- „
.....:... ...:.. 4.00 -_ •,.
ACC.DATE
ACC. FILE NO.,.- .
WATERTREAT.ING EQUIP. 4.00
WORKFRS'COMPF.NSATION DECLARATION
-
I hereby affirm that 1 have a certificate'of e.ment to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
-
ZONING
ENG. SITE N0.
copy there f (Sec. 800, Lab C.). ,aT
Policy N ompany' • rj �j lam-
-
FIRE SPO INK
v N
❑ ❑
ENERGY TQa
v N
❑, ❑
_.,....
❑ Cerlifie Copy hereby furnished. "
Cerlifi co is fit iCl It city ction division.
pplicant
MISC. - REFER TO ORD.
....RERMIT.ISSUANCE«:=.'-
CERT( FICA OF EXEMPTION FR WORKER$'
..,.,.;..500.
.. -'-"
PLG. CONTR. LIC. NO.
._ -
PLG. -
TOTAL
C 1PF:NSATION INSURA F
(Phis section need no4"ba-ecNnpIS ed. iLlFls:_prtmiL,is,fDG, we
y ❑ N ❑
V ❑ N❑
hundred dollars(SIOO) or less.) - -"'
I certify that in the performance of the work for which this per-
mit is issued, 1 shall not employ any person in any manner so us to
"' "" .' -
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
-
become subject to the Workets Gumperation. L:a rmfCwHinchniu:;';
Date APPlicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption,you. should becomgiub)ecl to the. Workers Compensation
srvisions of the Laor
ueh provisions or th sbpermtdshallobe deemed revoked. ovrpfy. wLLh
--- - •- - - - - -
.L... __.....
ALTER OR ADD TO MECH". 4.00
BUILDfNG',
. „
+a S�
/ - r
_ APPLIANCE 4.00
--
'AIR FIANTOL(NG.UNIT CTO' 10 GF.M.1"""3.00 "
PLAN CHECK
-FEE_._ ..
_, .....
AIR HANDLING UNIT (OVER I0,000C.F.M.) 5.00
SEISMIC FEE
63
- CONSTRUCTION LENDING AGENCY
EXHAUST H000 (WITH'DUCT) 2.00
MICROFILM
'
1 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 IQVERj00,0008'T:U:17:50^- -`
'•ELECTRIC"
Lender's Name ..
Lender's Address "' - "
I certify that l have read this application and.Stute that the above
information is correct. I agree to COmply_w1BLaILutY..apd.L rRY
'i'' i
ordinances and stale laws relaimg fo building construction, and
VENTILATION FAN (SINGLE) 3.00
PLUMBING
-- •-- -
-
,_
""'BOItER•COMPI3 H.P.or-100,000B.T.U.)- 4.00 ---•---
•'� '•
-
BOILER -COMP (Over 100,00b BTU) SEE FEE SCH.
MECHANICAL
hereby authorize. representatives of this city to enter upon the
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and peep?arniless'flie CCY �T
Cupertino against liabilities, judgments, costs and expenses which
may id a Way accrue against aid City in consequence of the
gra ting fl i;pe ,. _... ...._ f -.. - ..,..
Jl _ 5.T-",_ ,._.,,MFLM.CPCLT„..
/
��'-�--=- 'MISC.-, '„ -- -REFER-�T , -
--�- r _. ..,........
CONST. TAX
_.. _......_
..
PERMIT ISSUANCE 3.00
-..-_: .._. •.-TIC. NO._.- _ ......_
MECHL .. __ ._.
TOTAL
. .TOTAL_,. ..7/+'-/.3
J
Si/`g/n)a=i Applicant/Contract DZ
OFFICE COPY