3274 C11')' 01' CUPE1tTINO INSPECTIOPI RECORD (Office Copy)
3274 _ 10668 A MaplewoodN/S Dividers
• i'1;PJUT NO. SANITARY DIST. NO. LOT 110_ ADI)NES.S
Re-Model Property Services
PROJECT OWNER JOB SITE PHONE NO.
PERPIIT ISSUED Date ELECTRICAL
Buildins. ___ 5/25/83_ Date T.nsp.
Electrical 5/25/83 Power pole
Plumhiny _ Under ,round
Hc.chanical Routh l•liring
'Temp. Gas/Elect. flaLI.s
Solar Ceiling_
Fire Sprinkler Fixtures Int/Ext _
Sign Motors
Grounding
Hisc. Temp. Power _
Other
FINAI. INSPECTIONS Not Approved _
Date Insp.
r,rs .-- PLUMBING
Electric
Date Insp.
Plumbing Backflow
'Iechanical Underground
Solar Underfloor _
Pool Partial. Rough
• Gradin , Rough Complete
P Lanninp Solar Rough
Fire Dept. Water & Insulation
Health Dept. Plain Drain
Building 'f Z 3 R/of/S Drain
Other Gas
Other
BUILDING Not Approved
Date Insp.
Pad Certification HECIIANiCAL
Foundation Date Insp.
Pre-Gunite Underfloor S.N.
Slah-liembrane Ducts & Insulation
Bond Beam Fire Dampers _
Underfloor Girders Fireplace
Floor Steel Grease Duct & hood
Tiedowns One Hour Shaft
D.i.aphrams Condensate Drain _
Seismic ]lracinf, Equipment Anchorage _
Ual..ls-Panels Flues & Comb. Air
Frame Other
Lath Not Approved
Uallboards Int/Ext.
Firewalls
Other
. Not Approved
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI. POINT PEN ONLY
. BUILDING PROJECT IDENTIFICATION y ELI-ZX ERMIT NUMBER
BUILDING APPLICATION & PERMIT 3274
ADOREss BUILDING - ELECTRICAL-PLUMBING-MECHANIC
OVINER'S IPLAN CHECK VALIDATION
raE QTY. ELECTRIC PERMIT FEE
PHON
CONTRATORs OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME �y
LID.NO. LIGHTING FIXTURES 5.00/1.00 f� PAR)
c DNTRACTORs APPLIANCES-RESIDENTIAL 4.00
AODREss Aa1 y�/ qq
PHONE PANELS 5.00 MCIAkE da P � N
ARCHITECT SIGN$ 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER ILY Of Cu
tic.No. SIGNS TRANS. 3.00 Qrt
ARCH.OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
APPLANT'S MOTORS .SEE FEE SCH.
ADDRECSS
SERVICE CHANGE 10.00
o o LICENSED CONTRACTORS DF-CLARA'I'ION
I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Naw (commencing with Section 7000)of Division 3 of the Business and BLDG. 'ELECT. PLG. MECH.
r w z Professions Code,and my license is in full force mud effect.
z o F Li .Nuber
w
El 1:1 ❑
D ❑
Darc-Contractor.
a w¢
OWNER-BU RA'I'[OR BUILDING PERMIT
INFORMATION
D
w3 d 1 hereby affirm that I am exempt front tire Contractor's License MISC.- REFER TO ORD VALUATION
F ! o a Law for the following reason.(Sec.7031.5.BUalaess.nd Professions PERMIT.ISSUANCE 6.00 -
Code:Any city or ementy which requires permit reconstruct.alter. /a
2 improve,demolish,or repair any structure,prior to its issue"".also ELEC.CONTR. LIC.NO. ELEC. QQ
O K requires Ille applicant for Such permit to the u signed stulement that • TOTAL �� PERMIT TO
d w m a. he is licensed pursuant to the provisions of the Contractors License
F z i
Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe
- a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r O the basis for the:dle#ed exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; byanyappliesnt for a permit subjects file applicant to.coil pe nuttyALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500).1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do tire work.and the structure is not
intended or ottercd for sale (Sec 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who dues such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve-
ments are not intended Own a ereo for res,provided
that r.In he holding GAS-EA.SYSTEM-1 1NC.4 OUTLETS 4.00
or imprement is sold within one year of completion,tire -e owner- GAS EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
buiovlder will have the burden of proving that he did not build or im- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(See. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
dProfessions Code:The Contractor's License Law does not apply
an owner of properly.who builds or improves thereon.and who LAWN SPR IN KLERS-OVER 5 (EA.) 1.00 3=26_ 3.. j s�J-
contracts for such projects with a contmetots)licensed pursuant to
the Controaer's License haw. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lain exempt under Sec B.&P.C.Rlr this _ WATER HEATER W/VENT 4.00
reason
Dam Owner- WATER SYSTEM 4.00 ACC.DATE ACG FILE NO.
wOR IiRS'CO cls 5+'I ON DBCLn R.cI'1oN WATER TREATING EQUIP, 4.00
1 hereby affirm that I have a certificate o(cnnsent to self-insure. ZONING or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Se".3800,LBh.C.).
Policy No. Connpery
0 ❑ Certified copy is hereby furnished,
FIRE SPRINK ENERGYT2s
Z_ 2 ❑ Certified copy is fled with the city inspection division. MIS".- REFER TO ORD. Y ❑ NE] v [:] NE]
Applicant
CCPERMIT ISSUANCE 6.00 FLOOOZONE A.L.uc.
- CERTIFICA'fli 01:FXL'MPl'ION FROM WORKERS'
LU > CONPHNSATIO I INSURANCE PLG.CONTR. UC.NO. PLG.
CL 0 This section need not be completed if the permit is for one TOTAL v[:] N� Y N�
Z) Z hundred doll...IS 100)or less.)
U O I certify that 1"the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as to 9
Ow become subject to the Workers'Compensation Laws of California. BUILDING ;P I�
Date Applicant ALTER OR ADD TO MECH. 4.00 '-
} N NOT ICI7 TO APPLICANT: If,.1111,making Mix Cvu ificste of I'is
? emption,you slomId become 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 deemed revoked AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I 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(Sea MICROFILM
3097 CiaC) HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
ordinances n correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING �.
ordinances and smte laws eluting to building construction, anti my
hereby authentic representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for Inspection purposes.
(We) agree to cove, indemnify and keep harmless the City o1 MISC.- REFER TO ORD.
Cupertino against liabilities,judgmer s, costs and expense,which PERMIT ISSUANCE . :3.00 CONST.TAX
may in any way accrue against su' City in consequence of the
granting Of this per lit. MECH.CONT. LIC.NO. MECH. �[
3 TOTAL TOTAL / 6 -e
Sign tura o1 pplicant/ nm •or Da
OFFICE COPY