4881 __ .. CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
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. PERMIJ NO. ADDRLSSUwrhR
X10 N�
PR
PERMIT ISSUED ATE 'ELECTRICAL DATE INSP.
ui ing I 3 S
E eI ctrica
Plumbing Power 'Pole '
Mechanical er oun
Temp as ec ou irin
Solar Walls .
Fire Sprinkler Ceiling
Sign fixtures nt xt
- 'Rotors
Misc. Grounding
12�2 Power
Other
FINAL INSPECTIONS DATE INSP, of rove
Gas
Electric
_d__� �ui� �� __ PLUMBING DATE INSP.
ecFi E cam
.oar Backflow
ooh r und
. . . . . . . . . .
Grading er oor '
Planning artial Rou
Fire Dept. ou o ete
ea t e t. 50T,
o ar oug _
�uiTin ater 'F, Insulation
Other in am
TTOTTrNain
Gas
Other
BUILDING DATE INSP, Not rove
Pad Certification
oun ation ELECTRICAL DATE INSP.
Pre-Gunite
Slab-Nlembrane Underfloor S.M.
Bond Beam Ducts & Insulation
Underiloor Girders Fire D ers
Floor Steel Fireplim
ie owns Grease Duct 4 Hood
is rams e our S a t
eismec Bracing Condensate Drain
Walls- anels qu_ipment Anchorage
Frame F uses , Comb. Air
AWath Other
a oars Int/Ext. of prove
Firewa is
Other
Not Approved
BUILDING - -
5
ELECTRICAL
PLUMBING
•
D EMANICAL
DffSCELLANEOUS
APPLICANT TO FILL. IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
r• BUILDINGPROJECTIDENTIFICATION ' �F'T APPLICATION PERMTNDMRER
aDILDING • 4881
ADDRESS
I � .q 0L 0 BUILDING - ELECTRICAL-PLUMBING-MECHANIC
; - - -
NAME LAN CHECK VALIDATION
DTV. ELECTRIC PERMIT FEE
GWNER'S
S �J J(� A. e
NAME OUTLETS 6 OUTLETS-SWITCHES-RECEP 5.00/1.00
uc'NO. H LIGHTING FIXTURES 5.00/1.00 o
( neo css TORS ' APPLIANCES-RESIDENTIAL 4.00
PHONE '" PANELS 5.00 DATE OF APPLICATION
ARCmTECTPLAN CHECK FEE P.C.PI
OR - SIGNS 6.00
ENGINEER
Lic.NO. SIGNS TRANS: 3.00
ADDRESS ENG. CIRCUIT 5:00 PERMIT VALIDATION'
ZIP TEMP.METER OR , LI 15.00
APPLICANT - MOTORS SE ,FE SCH.
ADDRESS -
- SERVICE CHANGE" `10.00
woo LICENSED CONTRACTORS DECLARATION - - mss-,
F z w I hereby of firm that I um licensed under provisions of'Chaptcr 9 s .. yl�m 19SUA
(conmu i
Facing Willi Section 7000)of Division 3 of the Business and PAM
BLDG. ELECT. PL . MECH.
H u i Professions Code,and my license is in fall force and effect.
0 i L 0 License Class Lie.N'urnber
P,H Dalc Contractor CW
a m - BUILDING P RMIT
E ¢ w u OWNER-BUILDER DECLARATION' I 1 FOR TION
'0 y I hereby affirm that I ant exempt from the Convector's License _ MISC.- REFER TO ORD - '
FLLa Law fonhe;IDllowing reason.fSec.7031.5.Businessand Profeuionx PERMIT ISSUANCE vats N .
Code:Any city.or county which requires..permit toconstruct.Ater, 8.00 DO
¢ ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. TELE C. Q
u requires the applicant far such.perntit to file a signed statement that 1 TOTAL PERMIT TO
A w m he is licensed pursuant to the provisions of the Contr.¢mh License
r z i
Law(Chapter 9(commeneng with Section 7000)of Divisim,3 ofthc II JI
4 o Business and Professions Code)or that Ise is exempt therefrom and DTV. • PLUMBING PERMIT FEE
06
¢ H'W the basis for the alleged exemption.Any violation sal-Section 7031.5 STORIES TYPE CONSTR.
6 g _ by any umalicald for a pe riot subjects the applicant to a civil penally ,
of not inure than five hundred dollar,(S500f): -. ALTER-DRAIN& VENT-WATER (EA.) 4.00
❑ 1,as owner offhe property;or my employees with wages as BACK F LOW PROTECTDEVICE 2.00
their sole compensation,will do the work,and tile .e structure is not OCC.GROUP RES.UNITS.
intended or offered for sale (See. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AREA,COND. 4.00 '
Code: The Contractoh License Law does not apply to:ut owner of
property who buildsor improves thereon,and who does such work FIXTURES'-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
.• merits re through his own cmred fors.provided s,. such improve merits enot intended or employees. le.ILhowever.tile building GAS-EA.SYSTEM-11NC.4OUTLETS 4,00
or improvement is sold within one year of completion, the owner- GAS-EA.'$VSTEM-OVER 4 (EA:) 1.00 BUILDING USE
builder will have 'lie burden of proving that he did not build or un-
prosefor purpose ofsale.). . INDUSTRIAL WASTE INTER. RES IND CON I Orbe,
O 1,as owner of the property,am exclusively Contracting with 20.00 ❑ ❑ El ❑
licensed contractors to construct the project(See 7044.Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:'I'lie Contractor'sLicense Law dues not apply
to in owner of property who builds or improves tilereon.rand who LAWN SPRINKLERS-OVER 5(EA.) 1.00 - (
contracts for such projects with a contractors)licensed pursuant In •./� 6- 763^ 3/T
the Contractor's License Law. % SEWER-SANITARY-STORM EA.200ft/8.00 .TRACT No. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.lire Ibis WATER HEATER W/VENT 4.00
' 011
WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK Ii RS'CONIPI:NSA'TION DECLARATION,' WATER TREATING EQUIP, 4.00
I hereby atfinn that I have a ccnilicmeof consent it) -or a certificate of Workers'Compensation Insurance(ifr a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.). .
Policy N'o. • Company .
0 ❑ Certified copy'is hereby'fit ntished. FIRE SPRINK ENERGY T�Z4
Z z ❑ CenifieJ copy is fled with the city in.gxct ion division. FIRE
- REFER TO ORD.
O � Applicant - ' Y N V N
jr CERTI FICATE OF EXEMPTION FROM WORK Ii RS' PERMIT ISSUANCE - 6.00 FLOOD ZONE A.L.uc.
LLQ ' •COMPENSATION INSURANCE PLG.CONTR. - LIC.NO. PLG. v� NQ
CL O fY �. NO
rhis completedection need not completed if the permit is.fof one TOTAL
Z) z hundred dollars(S100).rtes I _ -
U O 1 certify slid in the perfonnance of the worClonwhich this per. DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL y-, n,il is issued,I shall not employ any person'in any manner so as to
0 U become subject to the Workers Contpcn.emion Laws of California, -
a Dar` Appl"am' - - I ALTER OR ADD TO MECH. - 4.00 BUILDING' Q 0
} W NOTICE TO APPLICANT: If,after making this Certificate of fix.
F z eruption•you should become staulet ,,the Workers Compensation ' - APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you most forthwith'emnPly will, FEE
U such provisions or Ihis permit shall be decnmd revoked. AIR HANDLING UNIT(TO 10)000GF.M.).. 3.00
CONSTRUCTION LENDING AGENCY, AIR HANDLING UNIT(OVER 10,000C.F.M.) 5.00 SEISMIC FEE - Sa
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 _
H¢ perliommncc of the work for which this perntil is issued(See. - - MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.P.50
Lendcri Address - ELECTRIC
I certify that I have,cad fills application and state that the above: VENTILATION FAN (SINGLE) 3.00
ordinances an correct. I agree to comply with all city untiots. and PLUMBING
ordinances and state lows relating lu building construction. and BOILER-COMP(3 H.P.ar 100,0000.T.U.) 4.00
hereby' authors, representatives of this city it)*enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City o1 MISC._.y - REFER TO ORD.
Cupertino against liabilities,judgmenls, costs and expenses which CONST.TAX
Inoy,in y way accrue against said City id consapmnce W the - PERMIT ISSUANCE 3.00
gmn'tg of Ihis perntil.
MECH.CONT. - LIC.NO. MECH.
*(� /-13 �I_ TOTAL TOTAL 3 yCS�
- SilfoL,re o'flCppitcant(C ..tractor - Date
OFFICE COPY