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C17'Y OF CUPERT'INO INSPECTIO1' RECORD (Office Copy)
0623 10380 Riviera Rd.
PE1,11IT 1I0. SANITARY DIST. NO. LOT NO ADDRESS
-5818
732
Sewer Only Teresa Carle 732-9400
PROJECT OWNER JOB SITE PHONE NO.
_ II
FINAL. INSPECTIONS
BUILDING
Date
Pad Certification
Insp.
Foundation
_
Pre-Gunite
Slab-Nembrane
Bond Beam
Underfloor Girders
Floor Steel
_
Tiedowns
_
Diaphrams
Seismic Bracing
Ual.ls-Panels
Frame
lath
llallboards Int/Ext.
Firewalls
Other
Not Approved
Date Insp.
Power Pole _
Under ,round
Rough Niring
11all s
Ceiling
Fixtures Int/Ext
Motors
Grounding
Temp. Power
Other
PLUMBING
Date
Backflow
Insp.
Underground
_
Underfloor
Partial Rough
Rough Complete
Solar Rough
4later & Insulation
_
"fain Drain
_
R/of/S Drain
Gas
Other
Not Approved
MECHANICAL
Date
Underfloor S.M.
Insp.
Ducts & Insulation
Fire Dampers
Fireplace
Grease Duct & hood
One !lour Shaft
Condensate Drain
_
Equipment Anchorage
Flues & Comb. Air
Other
Not Approved
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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY A)
BUI LDI NG PROJECT I DENTI FICATION
wau,
APPLICATION & PERMITADDRESS
PERMIT WTUR
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LUNG - -
10 �fgo 1
BUILDING -ELECTRICAL- PLUMBING - MECHANICAL
062 3
OWNER 57 PHGN 7Q
" E JJ 53 -1 &�
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- -
TY. ELECTRIC PERMIT FEECONT
PLAN CHECK VALIDATION
'
NAAMERACTDRs
OUTLETS - SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
LIC. NO.
,
CONTRAS DRESS DR's
AD
APPLIANCES-RESIDENTIAL 4.00
PANELS 5.00
' PHONE
DATE OF APPLICATION
RCHITECT
0.
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
ENGINEER ,
' LIC. No.
'
SIGNS TRANS. 3.00
ARCH OR LNG,
ADDRESS
SPECIAL CIR 5.00
PERMIT VALIDATION
ZIP,
EMP. ME POLE I 15.00
1
Ars
ADDRESooREsS
MOTORS SEE FEE SCH.
SERVICE CHAN411h 10.00
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Prnl'e.a."s Coda: and my license Is m full I()tee and effect
License Class Lie Number
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
❑ ❑ ❑
Date Ccimmdor
IN
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the fallowing reason.(Sec. 7031.5, Businessand Professions
Code: Any city or county which requires a permit to construct, alter,
MISC.--' REFER TO ORD
PERMIT ISSUANCE 6.00
VALUATION
SIFT.
ELEC. CONTE. - LIC. N0. ELEC.
TOTAL
- -
CITY. PLUMBING PERMIT FEE
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statennent that
he is licensed pursuant to the provisions of dm Contractor's License
Law(Chapter 9(commencing with Section 7000) of,Divisiun 3 offlic
Business and Professions Code) or that he is exempt therefrom and
PERMIT TO
_
,StCC/(S/L �/�/(.<
the basis for the alleged exemption. Any violation of Section 703 L5
STORIES
TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (S500).):
ALTER -DRAIN -WATER (EA.) 4.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
., OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
intended or offered for sale (Sec. 7044, Business and 1'rnfe',ums
Code: The Contractor's License Law does not apply to an owner of
'
FIXTURES - PER TRAP 4.00
GAS-EA.SYSTEM-l1NC.40UTLETS 4.00
So. FT. FLOOR AREA
TOTAL ACREAGE
property who builds or improves thereon, and who docs such work
himself or through his own employees, provided that such improve-
mentsarenotintendedorofferedforsale, If, however, the building
ar int p o
rove Is sold within one year .' complelion,•the owner-
builder will have the burden of proving that he dill not build or inn
GAS - EA. SYSTEM -OVER 4 (EA.) 1.00
BUILDING USE
p ove for purpose of sale.).-
�j I, as owner of the property, am exclusively contracting with
RLS IND CON PB Ooer
El- ❑ , El E] Elic
. .
INDUSTRIAL WASTE INTER2000
lensed Contractors to construct the project (Sec 7044, Business
and Professions Cnda: The Contractor's License Law does not amply to an owner of properly who hinds or improves thereon, and who
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
conthe oPoLeir projectswithucontractor)s) licensed pursumv to
the ctsforContractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00 0"U
TRACT NO.
PARCEL NO.
❑ I am exempt under Sec. ,B.&I'. C.AEq'his
reason I n .7A / \
-'Kll
WATER HEATER W/VENT 4.00
Date �Jil- AF +� nw, ��r'•pp������66��
WORK FRS'COM I:NSATIO )• . 7T-MI
WATER SYSTEM. 4.00'
.ACC.DATE
'
ACC. FILE No.
WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or u certified1
ZONING
ENG. SITE NO.
co py t hereof (See. 3900, La b.C.).
u/]Aj,
Policy No. - Company
-
❑ Certified copy is hereby furnished
❑ Certified copy is filed with the city inspection division.
Applicant
-
-
FIRE SPRINK
Y ❑ N ❑
ENERGY T 24`
Y ❑ N❑
MISC- REFER TO ORD.
CERTIEICATEOE EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOODZONE
A.L.U.G.
COMPENSATION INSURANCE
e permit is one
1'rhis section need not he completed if tire
Y ❑ N ❑
Y ❑ N ❑
PLG. CONTR. LIC. NO.
PLG.
TOT AL E "
hundred dollars IS 100) or less I
I certify that in the perforomnce of the work for which this per,
mit Is Issued, I shall not employ any person in any Caner so as to
DTV. MECHANICAL PERMIT FEE
FEE SUMMARY
become subject to the Workers' Compensation Laws of California.
ALTER OR ADD TO MECH. 4.00
Dale Applicant
BUILDING
-'
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
APPLIANCE 4.00
AIR HANDLING UNIT (TO 10=CF.M.) 3.00
PLAN CHECK
FEE
emption, you should become subject to the Workers' Compensation
Provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall he deemed revoked.
AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00
SEISMIC FEE
CONSTRUCT ION LENDING AGENCY
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 (Sec.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address
HEATING UNIT (OVER 100,000 B.T.U.)7,50
ELECTRIC
VENTILATION FAN (SINGLE) 3,00
I certify that I have read this application and slate that the above
information is correct. I agree to comply with all city and county
.mimmor, and slate laws relating to building construction, and
PLUMBING
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 4.00
hereby authoriseDepiesturtivcs of this city to enter upon the
hhuvc-mentioned property for inspection motrWs,
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
IWO agree to save, indemnify and keep harmless the City of
MISC. - REFER TO ORD.
Cbj?ertino against Induli' , Judgments, costs and expenses which
ma in any way ace a agui t said City in misequence of he
gran g of this pemlit �� a
PERMIT ISSUANCE 3.00
CONST. TAX
MECH. CONT. LIC. NO.
_
MECH.
TOTAL
TOTAL
Signan eof PP icam CL act r Uate
OFFICE COPY