0895 ciry OF GL'PER1'1NO INSPYGTIOt! RECORD (Off ice . Copy)
08957481 Rolling Dell Dr._
PERMIT N0. SANITARY DIST. NO. LOT NO_ ADDRESS
iReroof Dale Meyers
PROJECT OWNER JOB SITE P11014E NO.
PERMIT ISSUED Date ELECTRICAL
Buil dine 8-10-81 Date Insp.
Clectr_ical Power Pole _
1'111mhing Underground
Mechanical Rough Wiring
Temp. Gas/Elect. Nails
Solar Ceiling
Fire Sprinkler Fixtures Int/Ext
Sign Motors
Grounding
Hisc. Temp. Power
Other
FINAL INSPECTIONS Not Appiroved
Date Insp.
acs PLUMBING
Electric
Plumbing Date Insp.
Backflow _
Mechanical Underground _ ____
Solar Underfloor
Pool Partial Rough
Grading Rough Complete
• Planning Solar Rough
Fire Dept. Water & Insulation _
Health Dept. ?lain Drain n
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-Ilembrane Ducts & Insulation _
Bond Beam Fire Dampers
Underfloor Girders Fireplace
Floor Steel crease Duct & Hood
Tiedowns One (lour Shaft
Diaphrams Condensate Drain
Seismic Bracing ISquipment Anchorage
Ual.ts-Panels Flues & Comb. Air
Frame Other
Path Not Approved
Wallboards Int/Ext.
Firewalls
Other (_
Not Approved
6,PPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN
r BU I LDING PROJECT I DENTIFICATI ON ERM IT NUMBER
EDILDING APPLICATION & PERMIT
AOORESS ^ , / q�`� 0895
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
X OWNER'SPLAN CH ECK VA LIDATION
NAMfi-/�7 ONE�O OTY. ELECTRIC PERMIT FEE
CONTRACTORS
NAME ./ C-jy OUTLETS-SWITCHES-RECEP 5.00/1.00
7 /�9NC67 f<oaPO'Na, 3b j3S� LIGHTING FIXTURES 5.00/1.00
CONTR ADDRESS
APPLIANCES-RESIDENTIAL 4.00
AOOREas J q /' qq
UJ ,, L TONE -,9t PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.NO. SIGNS TRANS. 3.00
ARCH.DR'Ess ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLICANTS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
woo LICENSED CONTRACTORS DECLARATION
a u w I hereby affirm that I am licensed under provisions of Chapter 9 j CUPLHIINU
ISSUANCE DATE
v, (commencing with Section 7000)of Division 3 01(he Business and
Q n BLDG. ELECT. PLG MECH.
r y i Professions Cod rl d my license is in full lore-- rt effect.
❑ ❑ ❑
z O m - License ss Lia Numbcr_.2Lv$,3 J_n
0 m r Dntc
aY s ✓S/"'"'-" BUILDING PERMIT
EC CC 4 OWNER-BUILDIiR UIiCLARA'I'ION
A 0 a u INFORMATION
w ; LL 1- 1 herchy affirm that I am exempt from the Contractor's License MISC.- _A,E)FER TO ORD
F u 0 J Law for the following reason.(Sec.7031.5,Businessend Professions PERMIT ISSUANCE 6.00 VALOATION $/FT.
,A Code:Any city Drcounty which requires a permit to construct,alter,
/
SC a, im ouve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
a w m¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
z <
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
F i D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
H $ the basis for the alleged exemption.Any violation of Secllum 7031.5 STORIES 7 TYPE CONSTR.
T 3 byiny applicant fora permitsubjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4,00
of not more firm five hundred dollars($500).):
❑ 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 the work,and the sl torture is not
intended or offered for Sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contmclor's License Law docs not apply.to an owner of -
prnpiny who builds u In mous IhCRUr,and Who d0[S 511[1 work FIXTURES-PER TRAP - 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
hiell
ar r Through his own employees, 1,H,ed thin however,t h build ve-
meats aro not....ug nhis or employee arle.11'ded whithe building GAS-EA.SVSTEM-11NC.40UTLETS 4.00
or improvemmat is Sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or am-
PROW,for purpose ofsale.). INDUSTRIAL WASTE INTER. 20.00 - RES ,IND CON PB Omar
❑ Las owner of the property;am exclusively contracting with ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's license Law does not apply ,
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conlrucloos)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sea ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA'f ION DCCI.ARA'f1ON WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of ConsmG to sell-insure,
nr a cerlit'icale of Workers'Campellyatlon Insurance,or r certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy Na Company
0 ❑ Certified copy is hereby furnished. FIRE SPR WK ENERGY T-24Z Z ❑ Certified copy is Ned with the city inspection division. MISC.- REFER TO ORD.0 Applicant Yo. N❑ Y ❑ N❑
CC W CERT'IIICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.C.
LU > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL 0 (This section need not he completed if(he permit is for one TOTAL Y❑ N❑ Y❑ N❑
Z hundred dollars IS 100)or loss.)
(� O I certify that in the performance of(he work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued, I shall not employ any person In any manner so 16(o
O bec.r Ipjx t to the Workers',�ympensa'o Ln f lifor h.
O 0. Dnfed NApplicant�Sr_4Y�.. " _ ALTER OR ADD TO MECH. 4,00 BUILDING CzS'Yjti_.
} to NOTI li O APPLICANT': If,after mukmg this CCrlificate of Ex-
Z Omption,you should beconm subject to the Workeri Compensation
_ APPLIANCE 4.00 PLAN CHECK
Provisions of the his pc Cade,'II II mull to revoke comply with FEE.
,: V such Pnrvlsians or this permit shall be deoumd revoked. AIR HANDLING UNIT(TO 10)000QF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.FM,) 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(Sec MICROFILM
3097,Civ CA HEATING UNIT(TO 100,000 B.T.U.) 4.00
L.mc,Lender's Ndme
AHEATING UNIT(OV ER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that l have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
information elion is State. I agree to comply with all city and county PLUMBING
o formatio and state laws relating to comply
building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of (his city to ember upon the
above-mentioned property for inspection purposes, BOILER-COMP (Over 100,000 BTU)SEE FEE$CH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. '
CuPertino against liabilities,judgments, costs nod expenses which PERMIT ISSUANCE 3.00 CONST.TAX
nmy in any way accrue"against Said City in consequence of the
go...lingo,lhis pe,r,m,LI / �j - MECH CONT. LIC.NO. MECH.
k �Q✓L n e// ic�I G14? V1,0AL TOTAL TOTAL OZS;s�
Slgna(um of Appllcnnt/Contractor )ate '
OFFICE COPY