4059s
u
•
.•
CI"P1' OF CU1'17li1'LNO INSPYCTIOII RECORD (Office Copy)
/,,,),in __ 10160 D.n•leon
PEP11IT N0. SANITARY DIST. 140. LOT N0. ADDia`.SS
e')iace roof Ronald Miller
1.PROJECT 01dNER JOB SITE PHONE NO.
PERMIT ISSUED Date 11 Fl.r.r.TRTCAI.
P Iumhinr 3-12-33
Hochanical
1'emn. Gas/fleet.
FINAL. INSPECTIONS
BUILDING
Date Insp.
Pad Certification
Foundation
Pre-Gunite
Slab -Membrane
Bond Beam
Underflnor Girders
Floor Steel
Tiedowns
Diaphrams
Seismic Bracing
Ilalls-Panels
Lath
Uallboards (Int)Ext.
Firewalls '—
Other
Not Approved
PLUMBING
Date
Backflow
Insp.
Underground
Underfloor
Partial Rough
Rough Complete
Solar Rou ,h
Water & Insulation
Main Drain
R/of/S Drain
—�
Gas
Other
Not Approved
MECHANICAL
Date
Underfloor S.M.
Insp.
Ducts & Insulation 1 ^-8
Fire Dampers
Fireplace
Grease Duct & Hood
One (lour Shaft
Condensate Drain
Equipment Anchorage
Flues & Comb. Air
—�
Other
Not Approved
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
OFFICE COPY
APPLICATION & PERMIT
BUILDING -ELECTRICAL -PLUMBING -MECHANIC
PERMIT NUMBER
'4059 oC(�
4{ J J
PLAN CHECK VALIDATION
SuILDING
ADDRESS u'�7
o31A 1 eA1k SON
r OWNER'S
NAME II p
- -- -
QTY. ELECTRIC PERMIT FEE
Nlfi'l C_�\�< PHONE
DATE OF APPLICATION
CONTRACTOR'S
NAME (-
!'(,�1U5\ONe CCIV5+ UC.No. 360, /v
OUTLETS -SWITCHES -R ECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
CCIG
ADDRESS
LUDOC' W'"5 PHONE �cQ��t%��
- APPLIANCES - RESIDENTIAL 4.00
PANELS 5.00
ARCHITECTSIGNS
OR
ENGINEER
uc. NO.
6.00
PLAN CHECK FEE P.C. N0.
SIGNS TRANS. 3.00
ARCH. OR ENG,
ADDRESS
SPECIALCIRCUIT 5.00
PERIA VALIDATION
PA D
TEMP. METER OR POLE INS. 15.00
ZIP
AUG 121983
APPLICANTS
ADDRESS
MOTORS '- - SEE FEE SCH.
SERVICE CHANGE 10.00
�f COpCI'IIfIU
LICENSED CON TRACTORS DECLARATIONClty
I heehy affirm that 1 am licensed unifier provisions of Chnpter9
(u..loo cin, with Section ]000) of Division 3 ol'the Business eUl
Professions Code nd my license is in full force pnJ g4ck
License ors Lic Number, , 3
U ale _�' �- Contract.,
Contract., SYrM
OWNER -BUILDER DECLARATION
License
I hereby affirm the I on exempt 031,1 the Qt,Os anti
5.aj tlusiness Rnd Processions
Law for thcity or coung nt which e. requires
Code: Any city or county which structure permit toconstruct,alter,
ISSUANCE DATE
R
ELECT.
❑
L M C
BUILDING PERMIT.
INFORMATION
MISC. - REFER TO ORD
PERMIT ISSUANCE 6.00
VALUATION
$/FT.
improve, demolish, nr repair h p structure, prior to its issuance, also
also
requires the applicant for such permit t1 file a signed statement that
he is licensed 9 t to The previsions of the Contractor's License
ELEC. CONTR. LIC. N0. ELEC.
TOTAL
'
�r
PERMIT T
CITY. PLUMBING PERMIT FEE
(coo of Division 3 of and
Law (Chapter 9 (commencing with Section 7s exempt
Rosiness and Professions Code) or that he is exemptccUlntherefrom and
r
0NS
5 DRIES
TYPE CONST .
the bass for Illi alleged cxmnptiun. Any vialallln of Section ]031.5
by anyapplicam for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (5500).):
��„/ �%
�ft'Fi.
ALTER-DRAIN-WATER(EA.)4.OD
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure Is not
BACK FLOW PROTECT. DEV ICE 2.00
OCc. GROUP
RES, uryrt
DRAINS -FLOOR, ROOF, AREA,COND. 4.00
intended or offered for sale (Sec, 7044, Bustoys and Professions
Code: The Contractor's License Law does not apply to an owner of
FIXTURES - PER TRAP 4.00
SO.FLFLOORAREA
TOTALACREAGE
property who ltnllds or improves thercon,and who does such work
himself or through his own employees, provided that such impmvc-
.cuts are not intended or offered for sale. If. however, The building
GAS-EA.SYSTEM-11NC.4OUTLETS 4.00
or improvement is sold within one year al ' completion, Ile owner
builder will have the burden of proving that he did not build Lir ins
prove for purpose of cola.),
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 1.00
BUILDING USE
IND CON PR Out,
R ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
licensed contractors to construct the project (Sec. 7044. Business
and Professions Code: The Contraltos', License Law does not apply
Ass E551R5 PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
to an owner of property who builds or improves Thereon. and who
contracts for such projects with it coniractons) liccmcd pursuant ne
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO,
PARCEL NO.
❑ Iarnexemptwlder Sec. ,If&P.C.linthls
reason
WATER HEATER W/VENT 4,00
Date Owner
WATER SYSTEM 4.00
ACC. DATE
AcG FILE NO,
WATER TREATING EQUIP. 4.00
WORK EiRS'CONIPENSATION DECLARATION
1 herchy affirm that I have a ccHilicale of consent to sell'-ilssem,
or a certificate of Workers' Campensalion Irmo once. or a certified
ZONING
ENG. SITE NO.
copy Thercof (Sec. 3800, Lab.C.).
Policy Nn. CoUI
FIRE SPRINK
V ❑ ry❑
ENERGY T 24
v ❑ N❑
❑ Certified copy it hereby furnished.
❑ Certified 1 til[ w the 1
py t y spcctinn Jivisiml'
Applicant n
MISC.- REFER TO ORD.
CERTIFICATE 01' EXENIK ION FROM WORKERS*
PERMIT ISSUANCE 6.00
FLOOD ZONE
AL.U.C.
CO,NIPELNSAIION INSURANCE
I This section need not be completed if the permil is fur,onc
Y ❑ N❑
Y ❑ N ❑
PLG. CONTR. LIC. NO,
PLG.
TOTAL/e e
hundred dollars IS 100) or lcaJ
V /
I certify that in tire pert'ormanee of dm work far which this per-
mit is issued, I shall not employ any person in any manner so as to
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
.�y
become subject 11 the Wcrkcri Compensation pensaon Laws of California.
Date Applicant
NOTICE 10 APPLICANT: If, after nuking this Certificate of I.,-
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
AIR HANDLING UNIT (TO 10=C.F.M.) 3.00
PLAN CHECK
FEE
imp fion, you should become subject n, the Workers' Compensation
provisions of the Labor Code, you most forthwith comply with
such provisions Lir, this permil shall be deemed revoked.
AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00
SEISMIC FEE
3 �S
CONS"f RUCHON LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
The performance of the work for which this permit is issued (Set.
3097, Civ.C.r.
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's
Lender's Address
Addy
HEATING UNIT (OV ER 100,000 B.T.U.P.50
ELECTRIC
I certify that I have read this application and state that the above
information is correct I agree to comply with all city and county
ordinances and slot, laws relating to building construction, and
VENTILATION FAN (SINGLE) 3.00
PLUMBING
BOILER- 001 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTUI SEE FEE SCH.
MECHANICAL
hemhy auf o rve rep3esenmtives of Ibis city to titter upon the
aboveinenlinned property for inspection purposes.
(We) agree to save, indemnify and keep hinnless the City of
MISC. - REFER TO ORD.
Cupertino against liabilities, judgments, costs and expenses which
mayway accrue against said City in consequence of the
•rand Iy f Ihl�pcnnil.MECH.
4� �
PERMIT ISSUANCE 3.00
CONST. TAX
CONT. LIC. NO,
MECH.
TOTA /fD
TOTAL
_31,
Signal ere of Applicant/Conlru tot U Ic
OFFICE COPY