1035r �
0
C1"1'Y 01' CUPFRT'1NO INSPECTIM! RECORD (Office Copy)
1035_ 7562 P.irwin Lane
P1:11111,17 MO. SANITARY DIST. NO. LOT NO_ ADDRESS
Reroof Mn. Sewell 252-3680
PROJECT OWNER JOB SITE PHONE NO.
PERMIT ISSUED Date II ELECTRICAL
FINAL INSPECTIONS
BUILDING
Date I Insp.
1'ad Certification
Foundation
Pre-Gunite
Slab-Hembrane
Bond Beam
Underflnor Girders
Floor Steel
Tiedowns
Di.aphrams
Seismic Bracing
halls -Panels
Frame
I,nth
then
of P
s
nt/Fxt.
IPower Pol.e
Ron 'h
Ilalf.s
Ceilin
Fixtur
Ten
Ott
PLUMBING
Date j Insp.
Date
Backflow
Insp.
Underground
Underfloor
Partial Rough
Rough Complete
Solar Ron ,h
_
Water & Insulation
"lain Drain
R/of/S Drain
Gas
Other
Not Approved
MECHANICAL
Date
Underfloor S.N.
Insp.
Ducts & Insulation
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 ON
y
- PE UMBER
BUILDING"PROJECT IDENTI FICATION
ADDRESS "
BUILDING
• OFFICE COPY. --
APPLICATION.&PERMIT ,
BUILDING —ELECTRICAL— PLUMBING —MECHANICAL
v
JJ
1 O3[
PLAN CHECK VALIDATION
1�
i (o y�j r W 1 n La NPi
OWNER'S -
NAME
W p� I �5z—Tj
TY. ELECTRIC PERMIT FEE
"{ 1 V of PHONE
m
'
OATS OF APPLICATION
NAMERAcioRs - r^1
GHE12 Con C. No. `40P3
OUTLETS -SWITCHES- RECEP, 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
CONTRACTORS -
ADDRESS .�..�ar n f. 2
' C _1"7 l„] OLY' nr• PHONE ��—��y�
PPLIANCES-RESIDENTIAL 4.00
PANELS ' - 5.00
AARRCHITECi
ENGINEER
LIC. NO,
SIGNS g.00
PLAN CHECK FEE P.C; NO.
SIGNS TRANS. - 3.00
ARCH. OR ENG. -
ADDRESS -
SPECIALCIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00
• ZIP
"
ADDRESS is
ADDRESS
MOTORSSEE FEE SCH.
SERVICE CHANGE 10.00
�j-
LICENSEDCONTRACTORSDECLARATION
-
I hereby affirm that I am licensed under provisions of Chapter 9
I (commenting with Section 7000) of Division 3 of the Business and
Professions Coded ty license is in full force and of et
License Class_�17_J LIC. Number�'MQ �_
ISSUANCE DATE
- -
BE G.
ELECT.
❑
PLG. MECH.
❑ ❑
-
Date—��_Conlractor 11 teie&�r
OWNER -BUILDER DECLARATIO;81 2Z?S
I hereby affirm (hat I am exempt from the Contractor'S Li arse'
Law for the following reason. (See. 7031.5, Businessand ProfessionsPERMIT
Codc'. Any city of comity which requires m permit to construct, alter,
improve, demolish, or repair any Structure, prim 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 of the
Business and Professions Code) or that he is exempt therefrom and
.IXI
Ir—'
BUILDING PERMIT_
INFORMATION
MISC, - REFER TO ORD
VALUATION
0
0,!
$/FT.
ISSUANCE 6.00
ELEC. CONTR. LIC. NO.
ELEC. - -/O
TOTAL
PERMIT TO
D
r(ty E�QOI�
'
OTY. -PLUMBING PERMIT FEE
STORIES
. TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
-
by any applicant for a perrof subjects the applicant to a Civil penalty
of not more than five hundred dollars ($500T)
_
-
gLTERDRA III (EA.)
- 0 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 F LOW'P OTECT. DEVICE 2,00
OCC. GRDUP -
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND, 4.00
Intended or offered for sale (Sec. 7044, Business and Pm@ssloos
Code: The Contractor's License Law does not apply to an owner of
property who bu;lds or Improves thereon, and who dies SUCH work
himself or through his own employees. Provided that such improve.
ments are not intended or offered for sale. If, however, the building
FIXTURES - PER TRAP 4.00
SO. FT. FLOOR AREA
,
TOTAL ACREAGE
-
-
GAS- EA. SYSTEM; 1 INC.4 OUTLETS 4,00
or improvement is wild within one year of completion, (he owner-
builder will have the burden of proving that he did not build or in,-
prove for purpose of sale.).•
❑ I, Its owner of the property, am exclusively cmhtructing'with
. .
GAS EASYSTEM -OVER 4 (EA.) 1.00
BUILDING USE
RES IND CON PB Other
❑ ❑ ❑ ❑. ❑
INDUSTRIAL WTER• 20,00 '
licensed contractors t0' 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
LAWN SPR IN KL - 5.00
LAWN SPRINKL S - OVER 5 IEA. 7.00
ASSESSORS PARCEL NO.
-'
contracts for such projects with a contractons) licensed pursuant m
the Contractor's License Law.-,
SEWER -SAN ITAR - T Oft/6.00
TRACT NO.
PARCEL NO.
O 1 am exempt under See. ,B.&1•.C. tar this
reason
WATER HEATER W/VENT 4,Op
Dare Owner -
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO,
WATER TREATING EQUIP. 4.00
WORK ERS'COMPF.NSATION DECLARATION
-
I hereby affirm that 1 have a Certificate of Consent to sell=inane,
or a Certificate of Workers' Compensation Insur tt, ora certified
Copy thereof (Sec. 3800, Iab.C.l�4�►`' r
ZONING
ENG. SITE NO.
Policy No. —Company _}grls `l- I
• CICenlfietl 2opy is hereby fintished.
O Certift copy is Ne with t� • city inspec tin division.
Applicant
FIRE SPRINK
y❑ N❑
ENERGY T-24
I Y ❑ No
MISC- REFER TO ORD.
CERTIIICAT'li OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FL000 ZONE
0.uu.C.
• COMPENSATION INSURANCE
Lhis section need not he Completed if the permit is for one
Y ❑ N ❑
V ❑ N❑
PLG. CONTR. I NO.
-
PLO, -
TOTAL
hundred dollars IS 100) or less.)
e pern twice of the work for which this Pur-
' I cenlfy thatin (hfo
mit is issued, I shall not employ uny'person in any manner so as to
CITY. MECHANICAL PERMIT, FEE
FEE SUMMARY
BUILDING
,5'6 s -D
become subject to the Workers' Compenwtlon Laws of California.
Date—Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
ALTER OR ADD TO MECH. 4.00
- APPLIANCE 4.00
PLAN CHECK
FEE
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked. ,,
AIR HANDLING UNIT (TO 10,00DC.F.M.) 3.00
AIR HANDLING UNITIOVER 10=C.F.M.)6.00
SEISMIC FEE
A�d
CONS'I'RUCI'[ON LENDING AGENCY
I herehy-affirm that there is'a constructimn Icnding agency for
EXHAUST HOOD (WITH DUCT) 2.00
the performance of lite work for which this permit is issued (Sec.
3097,Civ.C.f
MICROFILM
-
HEATING UNIT TO 100,000 B.T.U.) 4.00
Lender'sAdde
HEATING UNIT ER 100,000 B.T.U.)7.50
ELECTRIC
'
Lender's Address
s
I cendy that l have.reudthis uP,ii,alian and state that the above
VENTILATION FAN (SINGLE) 3.00
-
information is correct. I agree to comply with all city and county
ordinances aid state laws relating to building construction, and
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 :mthoriee represeNativwof this city to enter upon the
above mentioned property for inspection purposes.
MISC. - h REFER TO ORD.
CONST. TAX
(We) agree to save, infemnit'y and keep Iwnnlass the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrete l against said City in consequence of the
PERMIT ISSUANCE 3.00
gra 'ng of thew Penn. t.
�GcG„t .CFJt��p� _ /,8
MECH. CONT. � LIG NO.
MECH.
TOTAL
TOTAL
S7 ''
'
Signature of Applmmht/Con tactor I',S Date
• OFFICE COPY. --