1047 1 CITY 017 CUPERTINO II1SPECTIOI! RECORD (Office Copy)
1047 _ _ 10371 Rivercrest_ Ct.
PCRtIIT NO. SANITARY DIST. NO. LOT NO, ADDRI;55
Shower Repair Mr. Van Beekum
PROJECT 01dNER JOB SITE PHONE NO.
PERMIT, ISSUED Date ELECTRICAL
11uiId•in�, U 9-11-81 Date Insp.
Electrical r } U Power Pole
1'11imll'inr y " Underground
llcchani.cal o Rou 'h Nirin _
I'emY. Cas/Elect. , t� 11alls
Sola' Ceiling
Fire "S rinkler: ._J Fixtures Int/Ext
Sin Motors
Grounding
Misc. Temp. Power
Other
FINAL INSPECTIONS Not Approved
4' Date Insp.
r"s PLUMBING
Electric Date Insp.
Plumbing Backflow
Mechanical Underground
Solar Underfloor
Pool Partial Rou h
Grading Rough Complete
Planninr Solar Rough
rite Dept . Water & Insulation i
Health Dept. *fain Drain
Buildin R/of/S Drain
Other _ Gas
Other
BUILDING Not Approved
Date Insp.
Pad Certification MECHANICAL
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 One hour Shaft
D.iaphrams Condensate Drain _
Seismic Bracing Equipment Anchorage
hIal..ls-Panels Flues & Comb. Air
Frame Other
Lath Not Approved
Wallboards Int/Ext.
Firewalls
Other
NotApproved
AA, 9-r9
fhna• pA,,. ¢.-srLL+T/s�
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ON
PER NUMBER
BU I LDING PROJECT IDENTIFICATION APPLICATION & PERMIT A O A
4
j' 9m LDING _ I
ADDRESS _
j e7_77 .e/l�/'tj� fiT BUILDING — ELECTRICAL—PLUMBING—MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME PLM... J ` OTY. ELECTRIC PERMIT FEE
MI ZA5:r � U/w1 PRONE
CONTRACTOR'S
Is // � UTLETS-SWITCHES-RECEP 5.00/1.00
p �/��-�Q�A�c.NoLIGHTING FIXTURES 5.00/1.00
CONTRACADDH ESSTORS PPLIANCES-RESIDENTIAL 4.00
z6( le.NE PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00 '
non Ess ENG, SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT$
ADDRESSMOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE - 10.00 p�
o o LICENSED CONTRACTORS DECLARATION
a U 1 hereby affum that I am licensed under provisions of Chapter 9 ISSUANCE DATE
v, w (commencing with Section 7000)of Division 3 Of the Business and
< u g BLDG. ELECT. PLG. MECH.
H y i Professions Coy.:Lpd my license is in full fort 8d ff. ❑ ❑ ❑
z o,i, — LicensSClass t' Coa Number
— D'JIC LC ��1 —CON raCfO _
a x s BUILDING PERMIT
¢ ¢o or a OWNER-BUILDER.D ARATIO INFORMATION
w ; 1 hereby affirm that 1 am exempt from the Contractor's License MISC.— REFER TO ORD
r u o¢ Law for the following reason.(Sec.7031.5,Business;md Professions pERMIT ISSUANCE 6 00 VALUATION $/FT.
y0 Code:Any city orcounty which requires a permit construct,alteq r/f
¢ w Q 0 improve,demolish,or repair any structure,prior to its issnaaca also ELEC.CONTE. LIG.NO. ELEC. /
' w0, requires the applicant for such permit to file a signed statement Ilial TOTAL PERMIT TO
wm Ile is lice ns ed pursuant to the provisions of the Contractor''sLicensc
Q'
Law(Chapter 9(commencing with Section 70000of Division 3 ofthe -' -S�ouia
4 o Business mol Professions Code)or that he is exempt therefrom coin QTY. PLUMBING PERMIT FEE
¢ H $ the basis for file alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant ma civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(S500).1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECTDEVICE 200
their sole compensation,will do the work,and the structure is not . .
OCC.GROUP RES.UNITS
intended or offered for sale (Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's Liecose Law does not apply to an owner of
properly who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- .
mems are not intended or offered for sale.If,however,the building GAS-EA.MTEM-1INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SY T -OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proem,that Ile did not build or all- IND CON PB ' Other
prove 1,aso nee of sale.). INDUSTR I AL WlYS TER. 20.00 0 _ 0 0 0 0
❑ I,as owner of the property,am exclusively contracting with
licensed contractors m construct the project(Sec. 7044,Business LAWN SPRINK ER$- 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code'.The Contractor's License Low does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINK OV IEA.) 1.00
' contracts for such projects with a contractor(s)licensed Pursuant to SEW ER- TARY- EA.200ft/6.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ Iain exempt under Sec. ,B.&P.C.Ibr this WATER HE M/VENT 4.00
reason
Line Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(See.3800,Lab.CJ. �r„
Policy No. Company Aeboyw 7 /ti
O ❑ Certified m is eby furnished.
Z Z ❑ Certifi FIRE SPR INK ENERGY R24
p Applicant MISC.- REFER TO ORD- Y � N� Y ❑ N[3
~ to C PERMIT ISSUANCE 6.00
:Kf114CATEOF EXEMPTION FROM WORKERS' FLOODZONE A.L.U.C.
LU > COb1PENSATION INSURANCE PLG.CONTH. LIC.NO. PLG.
(L o (This section need'not be completed it the Irernil is for one TOTAL Y❑ N[D Y ❑ N
Z) Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL I— mit is issued,I shall not employ any person in any nnumer sn ns to
U heconc subject m the Workers'Compensation laws of Qditio,nla.
du Uale Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} y NOTICE '1'O APPLICANT''. If,after making this Ce,til'iauc of F.-
�' Z
eruption,you should become subject to the Worked Campmisalion 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)WOC.F.M.) 3.00 -
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
1 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(Sec. MICROFILM
3097,Civ.C.). H EATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 -
Lender's Address ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information 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
mbrmordinances and state laws relating c to building construction, and
hereby authorise representatives of this city to en ler upon the BOILER-COMP (Over 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree
' Save'
indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino uguinst liabilities,juidgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may I accrue against said City in consequence of fife
gra I' Init. MECH.CONT. LIC.NO. MECH. -
9_//- ' TOTAL TOTAL /�z 00'
Signa G, EA ican on rector Date
OFFICE COPY