5778 CITY OF CUPERTINO INSPECTION RECORD .
(OFFICE. COPY)
• .-. - �. r151; M!!W3ll y YI ~`1 '- ��/� IVU•
rMUMA
UT,NER
PERMIT ISSUED DATE ELECTRICAL DATE INSP.
Buil ink
Electrical -'
E1um 1N - a_ �� Power Pole
rVcnanical - -�7Underground -
Tem as ec Xoujn Wiring _ --
Solar Wails a--
rare bPrinkler Ceiling_ -
sign Fixtures Int/Ext -Motors Grounding
UtTier
FINAL INSPECTIONS DATE INSP, ot . --
Gas aZ-744 --
Electric LL--7- r6l
?TcTiainca - PLUMBING DAIT INSP.
� -
ar _ _ Backflow
Ing Underfloor
PlanningPartialRough
Fire t.
Health-Dep—t. Solar ugni'
Building, _-
evrn
-- o , ain
,was
BUILDING DATE INSP, of prove -
Pad Certificntion vl / "!7
ounF'- atcT-'ion '
—Tj-�rr. � ELECTRICAL DATE: INSP.
Slab-Membrane doHle� Itr�� - Underfloor S.M.
Son am P ctsnsulationmwr-fl
oor Girders -7-3o ireers
Floor eLA T. 7-Ti&r ire ace - ---
ie owns ceaseuc Hood --- —
x a��ram_ si Hour--teat _
Seismeccracin - ensate ain -----
A-1'L- ane s , a .�.!_ _ - quipment�Fraw —_----- —
�- a I Ion(- Flu-est Comb Air— — --
_ ter
l�.mar nt �}ff of eve ------- -- -
��r'
ABS A[ -- r
'YL ve ��vyf;/ ^ ' ^
APPLICANT TO FILL IN INFORMATION WITHIN.RED LINES - USE BALL POINT PEN ONLY
,BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER
D - -. ,APPLICATION & PERMIT
A ,• e
GDRESS
pREBs22121 Lind Lane Lot X16 BUILDING'-ELECTRICAL-PLUMBING-MECHANICAL � 5778
OWNER'S - .?v $,r g PLAN CHECK VALIDATION
NAMMartin Ralstin 395=7320 D ;E FCT,gIC4PERMIT FEE 774.45
PHONE Od 8/'3/84
NAME 150.00
AcroRss - � /jig - 5.00/1.00
.'- LIC.No. f/ LIGHTING FIXTURES 5.00/1.00 pAID
'
AppRE55TOfl'S., , - s APPLIANCES 4.00 _ 11
;24.--
PHONE PANELS' - 5.00:- 4- QATE,QF 41141CATUIBINA
OORRCHITECT .S,IGNS, - _6.00 PLArfiNSOF FU U 14 C.N .
f
ENGINEER
' LIC.No, SIGNS TRANS. 3.00 '
ARCH.OR ENG. , P T
Agin
DDRESS;, SPECIAL CIRCUIT "'5.00
ZIP' EMP.METER OR POLE INS 15.00
APPLICANTS - MOTORS SEE FEE SCH.
N EO ' k IW U U/L SERVICE CHANGE ' 10.00
.LICENSED CONTRACTORS DECLAIItgION'StiT604 ' -
a u 1 hereby affirm that I am licensed under provisions of Chapter 9 ,� 84 ISSUANCE DATE
r- (commencing with Section 7000)of Division 3 of the Business and
,n<H , BLD ELEC PLG. MECH.
F m z Professions Code,and my license is in full torte and effect. .
z i o License Class La.Number CItY,of Cupertino
Date
Contractor
2 Ic w u
OWNER-BUILDER DECLARATION �* ?�; BUI IOING PE MIT
X ;u r 1 hereby affirm that'I am exempt from the Contractor's License MISC REFER TO ORD �N ORMAT ON
w u. '/� VALUATION $/FT.
H _0 a Law for the following reason (Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
Fw> � Code:'Any city)or county which rest uires a permit to construct,alter, - Imo+
¢ 2> O 'improve,demolish;or repair any Structure,prior to Its issuance,also ELEC-CONTR. LIC.NO. ,ELEC.
u O u requires the applicant for such permit to file a signed statement that TOTAL/ ERMIT TO
w m al he is licensed pursuant to the provisions of the Contractor's License „r,_
>
Law(Chapter 9(commencing with Section 7000)of Division 3 of the i' S4 F A M). i r, .w P Sjn le FaIRi1 Dwell.
z st Business and Professions Code)or that he is exempt therefrom and DT4Y•y, PLUMBINGTPERMLTs Tg#� PEE g y
a
the basis for the alleged exemption.Any violation of Section 7031 5 q+s,' '#*`^+ =L: �d' b%` * ;yfa'?7„Nav, (STORIES TYPE CONSTR.
aim by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER IEA.) q,00 - n
ofnot more than five hundred dollars($500).): {"' S N.' Hr.
❑ 1,as..net ofihe properly,or my employees with wagcsas / BACK FLOW PROTECT.DEVICE 2,00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intendedor offered for sale(Sec. 7044, Business and,Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contract6r's License Law does not apply to an owner of -
Properly who builds or improves thereon,and who does such work. /'i FIXTUR ES-PER TRAP 4.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve .
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4'OUTLETS 4.00 '
or Im pveinent is sold within one year of,completion,the owner GAS-EA.SYSTEM-OVER 4(EA.) 1.00 - BUILDING USE
t i_Il will have Ibe,burden of ReArK that he did not build or im
p for purpose of sale.). INDUSTRIAL'WASTE'INTER. - 20.00 RES IND CON PB Omer
as owner of'the properly,am exclusively contracting with 11, ❑ ❑ , O ❑
lic sed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to ao,6wner of property who builds or improves thereon,and who LAWN SPRINKLERS-.OVER 5(EA.)^ 1.00 356-27-16
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITAR EA,2001/6.00 . TRACT NO. .PARCEL NO.
❑' I am exempt and r Sec.' B.&P.C.for this �+
reason :. a Z WATER HEATER q•00 6401
Owner Dae / WATER SYSTE '+TsI ACC.DATE ACC.FILE NO. '
WORM COMPENSATION DECLARATION WATER TRE G O IP.`` 4.00 "
I hereby affirm that I have a certificate of consent to sal Ginsure, - ' ZONING ENG.SITE NO.
or a certificate of Workers'Compensation'Insurance;or a certified
copy thereof(Sec.3800,'Lab.C.). 'I
Policy No. - Company
00 Certi6edcupy ishereby furnished. FIRE SPRINK ENERGYTZ4
,'Z Z ❑ Certified copy is filed with the city inspection division.
p . Applicant MISC.- .I REFERTOORD. 'Y 11 N❑ v [:) N�
•jr W CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
ION
W , (This-action cod not beTcomple ed Rif[le permit is for one PLG.GDNTR. LIC
❑ NO. TOTAL ;Y,.❑ N❑' Y p Np
a.
02 hundred dollars(8100)or less) ar' c"`5�' ^R
LLI-
O I certify that in the performance of the work for which this per D.1.}�"]'"*'y k a i e�5, ' n` FEE SUMMARY
F mit Is'issued„I shall not employ an arson in any manner sn as to stir) S`=1MECHANICAOPERM1T FEE .s^a '
p Y' Y P t 5 1 p' t 4-b. #4*'# Ni.
0 W become subject to the Workers'Compensation Laws of California A r " f=
Date-Applicant BUILDING
a ALTER OR ADD TO MECH. 4.00 -
} to NOTICE TO APPLICANT:-.I f,after to the this Certificate sa Ex-
f- ? emotion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions-of the Labor Code, you-must forthwith comply with FEE
. C.1 suet)provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000GF.M.) 3.00
CONST RUCTION LENDING AGENCY AIR HANDLIN I VERIOPWC.RM.) 5.00 SEISMIC FEE `
1 hereby affirm that there is a construction lending agency for / EXHAUST HOO ( TH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). - . 'HEATI Nlf Q102000' 1*1
4.00
Lender's Name HEATIN NYYI VER 100,000 B.T.U.17.50
Lender's Address ELECTRIC
I certify'that I have read this application and slate that the above z• VENTI l I N FAN ISINGLE) , -.3,00
information is correct. 1 agree to comply with all city and county PLUMBING
brdinances and state'laws relating to building construction, and BOILF.A- ( [ . ®0,000 B.T.U.) 4.00
hereby authorize representatives eof this city enter upon the
above-mentioned property for
inspection ta purposes, BOILERve
-COMP'IOr 100,000 BTU)SEE FEE SCH. MECHANICAL �• /
ere
(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 accrue against said City in.consequence of the
granting of t is per t.
" t , MECN.CONT. LIC.NO. MECH. //////���lll
.\ Y - TOTAL" 3
11-��-�h/ -AA11// "h�JJ TOTAL`'' Z
Signature of Applicant/Contractor Date �
i OFFICE COPY
•
CERTIFICATE OF COMPLETION
BUILDING INSPECTOR'S OFFICE
J
CITY OF
OF CUPERTINO p
DATE ^ '1 19� BLDG. PERMIT NO.'-
THE
O.THE BLDG. LOCATED AT
OWNED BY
HAS BEEN OMPLETED( FO
CRUSE AS C 1J VU .VL I
(ALTERED)
4 t ,
BUILDING INSPECTOR