3293 CITY 01' CUI'iSR1'LNO .INSI'P:CTIOP! RECORD (Office Copy)
3293 — --_- 10658 B Ma
p]ewoo�i - -----
_ PEPJUT 110, SANITARY DIST. N0. LOT N0. ADI)PESS
Re-Model Property Services
PROJECT OWNER JOB SITE PHONE NO.
PERMIT ISSUED Date ELECTRICAL
Buildi.nr, _ 5/25/83 Date Insp.
EIe_ctrIca1 5/25/83 Power Pule
I'Iumhiug Under ,round -- -
1lcchani.cal Rough Uiring
Temp. Gas/EICct. halls _
Solar Cci-link_
Fire Sprinkler Fixtures int/Ext
Sign ilotors
Grounding _
Misc. Temp. Power
Other
FINAL INSPECTIONS Not Approved _
Date Insp. -
"s --- PLUMBING
Electric Date Insp.
PUimbin , Backflow
!Techanical Underground
Solar Underfloor
Pont Partial. lough
• Gradin , Rough Complete --
I'Lanni.nt; Solar Rough
Fire Dept . Water & insulation _
Health Dept. "lain Drain
Building R/of/S Drain _
Other Gas
Other
BUILDING Not Approved
Date Insp.
Pad Certification HECIIANICAL
Foundation Date Insp.
Pre-Gunite Underfloor S.M.
Sl-ah-Hembrane Ducts & Insulation
Bond Beam Fire Dampers _
Underfloor Girders Fireplace
Floor Steel _ Grease Duct & Hood
Tiedowns One flour Shaft
Diaphrams Condensate Drain
Seismic Bracing I.quipment Anchorage_ —
Ualls-Panels flues & Comb. Air --
Frame Other
Lath Not Approved
wallboards Int/Ext .
Firewalls
Other
. Not Approved
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTI F[CATION LQ PER NUMBER
BUILDING APPLICATION & PERMIT n
oDREss t'
BUILDING - ELECTRICAL-PLUMBING-MECHANIC
OwNER'S PLAN CHECK VALIDATION
ME DTV. ELECTRIC PERMIT FEE
(vQU PHONE 1 U.�� rw
dh
NOME c7oRs OUTLETS-SWITCHES-RECEP 5.00/1.007w:,,,
.00/1.007( � PAID
LIC.No. '7 LIGHTING FIXTURES 5.00/1.00 .S-
CONTRACTOR's 7/APPLIANCES-RESIDENTIAL 4.00 S' J Y 25193
A DORESS
PHOrvE PANELS 5.00 DATE OFAPPLICAT ION
ARCHITECT SIGNS 6,00 P.C.NO,
OR Y.
ENGINEER
uc.rvo. SIGNS TRANS. 3.00
ARCH OR ENG' SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ESS
ZIP EMP.METER OR POLE INS. 15.00
ADDRESS
Ars MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
00 LICENSED CONTRACTORS DECLARATION j
< u U I hereby uffirm that I con licensed under Provlsiuns of Chapter 9 ISSUANCE DATE
m A n (commencing with Section 7000)of Division 3 of the Businessand BLDG. ELECT. PLG. MECH.
F so z Professions Code,and my license is in full force and effect. ❑ ❑ ❑ ❑
o 0 w o License Class LIC.Number
Date Contra[lor
a x E c BUILDING PERMIT
¢ ¢ w 4 OWNER-BUILDER DECLARATION INFORMATION
SodF - MISC.- REFER TO ORD
w1 hereby affirm that I OR exempt Irom the Contractor's License
LL o j Law for the following reason.(Sec.703 t,5.Business and Professions PERMIT ISSUANCE VALUATION S/FT.
� - Code:Any city orcourry which reyuiresa permit to construct,alter. 6.00 aw
a ¢a 20 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, ELEC. a`/d 0
D u requires the applicant for such permit to file a signed statement that TOTAL r `� PERMIT TO
wK m he is licensed pursuunt t0 the provisions of the CmVnmtor's License
H z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofihe
s 4 D Business and Professions Code)or that he Isexenpt therefrom and
DTV. PLUMBING PERMIT FEE
¢ f p the basis for the alleged exemption.Any violation Of ScCt IUB 7031.5 STORIES TYPE CONSTR.
ate _ by any applicant for a permit subjects the applicant fair civil penalty ALTER-DRAIN -WATER (EA.) 4.00
.fn or
fnut more than five hundred dollars(55001.):
❑ I,as owner of the property or my employees with wager us BACK FLOW PROTECT.DEVICE 2.00
f OCC.GROUP RES.UNITS
ocir sole compensation,will do thtr
e work,and the iuctme is not
intended or Offered for Sale (See 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 -
Code:The Contractor's License Law docs But apply to an Owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 sir FT.FLOOR AREA TOTAL ACREAGE
himself re through his own emred fors,provided ev such improve-
hients mself enot int1 is or toredl'or,provided
last ethe mpro ng GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or'mpmvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that ha did not hard or int-
proveforpurpo.seol'sale.). INDUSTRIAL WASTE INTER. 20.00 RES UID CON PB Om.n
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct fire 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 in owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects will,a um,actors)licensed pursuanito
the Cnntmaor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under See-.It&P.C.for Hits WATER HEATER W/VENT 4.00
teaser
Date Owner _L WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORK I i RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby ffirm that I have a ce'lificit,of'Boum to self-insu« ZONING ENG.SITE NO.
or a Certificate of Workers'Compensation Insurance.or a certified
copy thereof(Sec 3800,Lab.C.l.
Policy No. Company
O ❑ Certified copy is hereby furnished: FIRE SPRINK ENERGY T 24
Z z ❑ Certified copy is Bled with floc city IllapCel lBn division. MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ Y 11 N❑
� N CERTIFICATE 01'EXEMPTION I7RONI WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.c.
LU �_ CO?IPENSWION INSURANCE PLG.CONTR. LIC NO. PLG.
1 0 ('This Section need not be completed if DIC pennit is for one TOTAL Y❑ N❑ Y ❑ N❑
0 z hundred dollars IS 100)or less.)
U O 1 certify that in the Parformuncc of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued,1 sno
kull t employ any person in m
any aso
nner as to
O W become subject to the Workers'Compensation laws of California. BUILDING (�
Date Applicant ALTER OR ADD TO MECH. 4.00
} N NOTICE TO APPLICAN'C If,after making this Certificate Of Ex-
F z emption.you should become subject to the Workerx'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwilh comply with FEE
U
act,providm,Br this pump shill he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1000OF.M.) 5.00 SEISMIC FEE SO
I hereby affirm that then is a conaructmo lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cis C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
HEATING UNIT(OVER 100,000 B.T.U.17.50 ELECTRIC
Address-Lender's Addyess
I certify that 1 have read this application and state that the shove VENTILATION FAN (SINGLE) 3,00
'Bfonamion is correct. I agree to Co...ply with all city and county BOILER-COMP13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
hereby
ordinances and stmt esen relating to building construction, and
above author e representatives ul Ihis city In come upon the BOILER-COMP (over I00J000 BTU)SEE FEE SCH. MECHANICAL
ahuvrmcntioneA property for inspection purposes.
(We) agree to save, indenmil'y and keep harmless the City'Of MISC.- REFER TO ORD.
Cupertino against liabilities,Jud menus, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue gat said City in consequence of the
grunting of this eras / MECH.CONT. LIC.NO. MECH.
m �b /A � TOTAL TOTAL 3�1
wtuo,Tii Appl can CI fleet or rUutc
OFFICE COPY