5532 CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
PhVMT NO. ADDRLSz; LOT NO.
! 8221110d Ju//1Iyw
ipT=1 OWNER
PERMIT ISSUED DATE "ELECTRICAL DATE INSP.
ui
in
h3ectrlcal
Plumbing "Power Pole
c anlca r oun
Temp ec ou irin Solar Walls
. '
Fire rine er 1 m
Sign Pixtures Int/Ext
tors
Misc.Grounding
Temp ower
Other
FINAL INSPECTIONS DATE INSP, NotApproved
Gas
Electric
Plumbing PLUMBING DATE INSP.
Mechanical
'lar Backflow
Ur oun
Grading r 0071
Plarmi-ng Tartialoug
Fire Dept. Hou h Co�lete
Health Dept. ar ou
1� Water '4 Insulation
gh
6t ergMain Drain
oDrain
Gas—
Other —
BUILDING DATE INSP. Not Approved
Pad Certification
Foundation 3 ELECTRICAL DATE INSP,
e
,�31ab-Membrane Underfloor S.M.
S d c d ( Ducts nsu anon
Underfloor Girder %s ire an ers
Floor Steel " ire ace
ie owns rease Duct & Hood
Diaphrams One Hour Shaft
beismec Bracing
Condensate Drain
al s- ane su�ment Anchorage
rte— _ dues 4 Comb. i r
qw1r ter
oar Int/Ext.t. of rove
'� c
rirewa s
Other
et rove
,APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATI PERMIT NUMBER
BUILDING APPLICATION & PER
°°"Eg7 5532
ING—ELECTRICAL—PLUMBING—MECHANICAL
Oen"R'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
ONTRACT°R- -J l0
NAME ,,pp � UTLETS-SWITCHES-RECEP 5.00/1.00
'�
"LIG Q LIGHTING FIXTURES 5.00/1.00 SSW
c.ONTRACTO 5
ADDRESS 0 PPLIANCES-RESIDENTIAL 4.00
ONE f/ PANELS 5.00 DATE OF APPLICATION
agCInTECT SIGNS 6.00 PLAN CHECK FEE .NO.
ENGINEER �_
' sac.No. SIGNS TRANS. 3.00
EOR
ENa s SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00 ID
APPLICANTS
ADDRESS MOTORS IF, SEE FEE SCH.
r SERVICE CHANGE 1PAD 0.00 AUG 4
w ¢z
-2 LICENSED CONTRACTORS DECLARATION 0 1Q94
is 1 hereby affirm that I am licensed male,provisions of Clnpter 9AUG
CI "gRCE IATCE
„z w (commencing with Section]000)of Division 3 of the Bmwee s and
G °N SLOG. I ELECT. PLG. MECH.
F y z Yrof vlons CaJt,and my liarisc n in full fore effuel. Q
x LEI
i,w o License Lo / Lic.Number ^ I �, I�
m r )ale_ �(y�.�J-Contractor Lam`
a x s BUILDING�PERMITj�e,�L
¢ ¢Be OWNER-BUILDER UECLARA
O a INFORMATION' ',-',`2. )
g; u_ r I hereby affirm Ih0 I am exempt from the Contractor's License MISC.— REFER TO ORD -
w o 7 Iaw for the following s,son.(Sec.7031.5.Basin send Prufes iom PERMIT ISSUANCE 6 00 Code:Any city or VALUATION
rounty which r- uires s permit to construct,alter,
x ¢ improve,demolish,or repair any structure,prior to Its issuance,also ELEC.CONTR. LIC.NQ ELEC. ^ / O OO
O LL ,padres the applicant for such permit to Pik a signed statement that TOTAL (7
PERMIT TO
e w m he is licensed pursuant t°the provisions of the Contractor's License
rzi
LID,(Chapter 9(commencingwith Section 7000).rDivision 7 oflhe �(��///d
4 a Baines therefrom and Professions Code)or that he is exempt therefroand QTY. PLUMBING PERMIT FEE,
¢ F-$ the basis for the alleged exemption.Any violation of Section 7071.5 STORIES TYPE CONSTR.
i 3 — by any applicant for a permit subjects the applicant t°a civil penally
of not more titan Five hundred dollan(S500).): ALTER-DRAIN St VENT-WATER (EA.) 4-00
❑ 1,as owner M the properly,or my employ with wagesu BACK FLOW PROTECT. DEVICE 2.00' C.GROUP RES.UNITS
their sok compensation,will do the work,and the structure is not
intended or offered for sake (Sec. 7004, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONE). 4.00
Code:The Contractor's Lice,nse Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 sa ET-FLOOR AREA TOTAL ACREAGE
imsclf or through his own employees,provided that such improve- _
kris are not intended or offered for sak.If,however,the budding GAS-EA.SYSTEM-l1NC-40UTLETS 4.00 170
ur improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 7.00 uaDING USE
builder will haw the burden of,moving that he did not build or im-
pose for p"rpoaofsale'). - INDUSTRIAL WASTE INTER. 2000 RES IND CON PB Ob.
❑ I,as owner of the properly,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
Iicenvd comractmrs to construct dhc project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Con Oactor's License law does not apply
to an owner M property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts fur such projects with a rontnclonO licensed purmant to _
lire Contractors Li law. f� SEWERSANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ tem exempt antler S--(Z /L� .B.&P.C.for tris
mann WATER HEATER WENT 4.00
Owee, t e, Date WATER SYSTEM ' 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 4.D0
I hereby atllrm that l have me mxacatr of consent 1.of sal zoomed ZONING ENG.SITE NO.
or a lentil ate of Workers Compensation Insurance,or a certified
Copy t he,eof(Sec.3S00, pDnyLab.C,I��.a,g
Policy Nn. Company J/l ed
O ❑ Ccr tied n it hcrehy rnntsed. FIRESPRINK ENERGY T 24
C— O pJU Ccrtifn 1 o fill '1 I ' lnspcdfon division. MISC.- REFER TO ORD. Y ry v N
cry CIiR'I'IItlCA'1'Ii OF EXEMPTION PRO ORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.C_U.C.
L COMPENSATION INSURANCE PLG.CONTR. LIC.No, PLG.
Z ('Phis section need not he completed if the permit 6 for one TOTAL Y 13N❑, Y C] N[]
U O hundred dullurs($100)or lcs,J ,
I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
L F mit is issled,I shall not employ any person in any manner m as to
O w become subject to the Workers'CmnpeE.(ion Laws Of California.
EdUutc Appinurd ALTER OR ADD TO MECH. 4.00 - BUILDING
} m 'NOTICE 'IU ALAN'f: If,alter making this Certificate of Ex-
F• 2 emptinn,you should bee(rec 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 dinemed revoked. AIR'HANDLING UNIT(TO 1QOWC.F.M.) 3.00
CONSTRUL71ON LENDING AGENCY AIR HANDLING UNIT(OVER lO=CF.M.15.00 SEISMIC FEE a'y�
1 heathy,affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) '2.00
the jacdommnce of the work for whit hu permit is issued(Sec. MICROFILM
3097,Civ.C.). 1 HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Add HEATI NG UNIT 100,000 B.T.U.)7.50 17
Lender's Addr- ELECTRIC
I ceHify mut 1 have orad this application and state that the above VENTILATION FAN (SINGLE) 3.00
rfnrmmi°n is correct. 1 agreee m comply with all city and county BOILER-COfeP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
diBoners and state laws relating tobuildingconstruction, and
ereby authorize fepr etativcs of this city to enter upon the
abovommntioned property for inspection purposes. BOILER-COMP IOxer 100,000 BTU)SEE FEE SCH. MECHANICAL
(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 areae against said City in consequence of the
gmntin f this permit. MTOTAL ECH.CONT, LIC.NO. M
� TOTAL 1p?�
drEc of pplicant/Con nc o, Dem -
OFFICE COPY