3273 CI'PY 01' CUPERl'INO INSPECTIOU RECORD (Office Copy)
3273 _ 10678 D Maplewood NIS Dividers
• PEPdIIT f10. SANITARY DIST. 140. LOT NO ADI)PESS ---�
Re-Model Property Services
PROJECT OWNER JOB SITE PIIONE NO.
PEF11IT ISSUED Date ELECTRICAL
Buildtnnr _ 5/25/83 Date Insp.
I:Iectrical 5/25/83 Power Pule
PIumhi T Under p,round -- -
-
iicchani.cal Rough Hiring
Temp. Gas/Elect. Ila la.s _---
Solar Ceiling
Fire Sprinkler Fixtures Int/Ext
Sign ilotors
Grounding _
Misc. Temp. Power _
Other
FLNAL INSPECTIONS Not Approved _
Date Insp.
r"s -- PLUMBING
Electric
Date Insp.
Plumbing Backflow
Mechanical Underground
Solar Underfloor _
Pool Partial Rough
• Cradin , Rough Complete
11Lanni.ng Solar Rough
Fire Dept. Hater f. Insulation _
Health Dept. "lain Drain
Building /b-1 Z-B3 R/of/S Drain
Other Gas
Other
BUILDING Not Approved
Date Insp.
Pad Cert.i.ficat.ion IIECIIANICAI,
Foundation Date Insp.
Pre-Gunite Underfloor S.M.
Slab-Hembrane Ducts & Insulation
Bond Beam fire Dampers
Underfloor Girders Fireplace
Floor Steel Grease Duct & hood
Tiedowns Onc (tour Shaft
Di.aphrams Condensate Drain
Seismic liracinf, Equipment Anchorage
llal..ls-Panels F] ues & 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
BUI LDI NG PROJECT I DENTI FICATION kALl PERMIT NUMBER
BVILDING APPLICATION & PERMIT 3273
• ADDRESS )c got7lF BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
7
OWNER'S AN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
VHONE
C rvTR
ernes
NAME Is OUTLETS-SWITCHES-RECEP 5.00/1.00
LIC.NO. 1 45 ILIGHTING FIXTURES 5.00/1.00
CONTRACTORS 2 PPLIANCES-RESIDENTIAL 4.00 41-d'V
ADDRESS - MAY p
PHONE PANELS 5.00 pA{ED A LI
ARCHITECTSIGN$ 6.DD PL CHECK FEE .C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00 /yOf CU
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALID N
ADDRESS
ZIP EMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
,E
SERVICE CHANGE 10.00
00 LICENSED CONTRACTORS DECLARATION
a u u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
H < w (commencing with Section 7000)of Division 3 of the Business unit BLDG. ELECT. PLG. MECH.
H N z 1'rofessions Code,and my license is in full force and effect. rA--A ® ❑ ❑
2 0. - License Class Lic.Number.
0 z r Date Contractor
< r a BUILDING PERMIT
w ¢ OWNER-BUILDER UECLA RA'T'ION INFORMATION
odea MISC.- REFER TO ORD
E
3 a E I hereby affirm that I am exempt from the Contractor's License VALUATION SIFT.
Ha0J Law for the following reason.(See.703 t,5.Business and Professions PERMIT ISSUANCE 6.00 .-
Code:Any city or county which requiresa permit toconstruc6uller, N ./a Z0
K¢ 0 improve,demolish,or repair any stricture,prior to its ismance,also FLED,CONTR LIG.NO. ELEC.
as 0 equires the applicant for such permit to file a signed statement Illat TOTAL PERMIT TO
a w
01 he is licensed pursuant to the provisions of the Contractors License
r z i Law(Chapter 9(commencing with Section 7000)of Division 3 of the
- a Business and Professions Code)(it that he is exempt therefrom and QTY. PLUMBING PERMIT FEE -
s the basis lint the alleged exemption.Any violation of Suction 7031.5 STORIES TYPE CONSTR.
i3$ by any applicant for a permit subjects the applicant toacivil penally gLTER-DRAIN -WATER IEA.( q.00
of not more than five hundred dollars(S500).):
❑ 1,as owner of the property,or my employees with wages a BACK F LOW PROTECT. DEV ICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will du lire work,and lire structure s cat
intended or offered for sale (See. 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 does such work F IXTUR ES-PER TRAP 4.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve-
meresLure'let intended oroffendfor sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion, fire owner-
GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,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.
and Professions Code:The Contractor's License Law docs not apply �/ j
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 6-
-f-
contracts
contracts for such projects with a contractorts)licensed pursuant to
the C'ontractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ l an,exempt under Scc. ,B.&P.C.for this WATER HEATER W/VENT 4.00
Cason
Date _ f_-OvvNCr- - r WATER SYSTEM 4,00 ACC.DATE ACC.FILE NO,
WORKERS' OMPIiNSA'fION UIiC LARATION WATER TREATING EQUIP. 4.00
I herchy affirm thm I have a certificate of consent to lclbinsure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insumnee,or u cert il'iad
copy therenf(Sec 3800,Lab.C.l.
Policy No. Company
O ❑ Certified copy isherehytinnished, FIRESPRINK ENERGYT24
Z Z ❑ Certified copy is riled with file city inspection division. MISC.- REFER TO ORD. Y N Y N
O Applicant ❑ ❑ ❑ ❑
CCN CERTIFICA11:0E I
EXEMPTON PROM WORKP.RS'- PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION NSURANCE PLG.CONTR. LIC,NO. PLG.
CL 0 (This section need not be completed if the permit is for one TOTAL Y❑ No , Y ❑ N❑
::) Z hundred dullars(SI00)or less.)
U O 1 certify that in the performance of lire work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- not is issued,I shall not employ any person in any manner so as to ryry .1h�q
0U beeline,object to the Workers'CampCnwtion Lawsot Culifonoa. BUILDING b•�-�`�
Uale Applicant ALTER OR ADD TO MECH. 4.00
} tail NOTICE"f0 APPLICANT: If,after making this Certificate of Ex-
F ? emplion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, You Trust forthwith comply with FEE
U such provisions or this permit shall be demned revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00 �-p
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10=C.F.M.) 5.00 SEISMIC FEE d "
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the perlbmiance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 a
Lender's Address ELECTRIC
I C
I certify that I have read this application and sine that the uhovc VENTILATION FAN (SINGLE) 3.00
'nfonnnion is correct, I agree to comply with all city and county BOILER-COMM H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize 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 m save, indemnify and keep harndess the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgmmnls, costs and expenses whichCONST.TAX
may in any way accrue against d City in co c4u .CC of the PERMIT ISSUANCE 3.00
granting of this p-nnit MCH.CONT. LIC.NO. MECH.
j �� orAl TOTAL
Slg ma o p leant/�-Codi Pastor Dale v
OFFICE COPY