3285 + CITY 01" CUPERT'INO INSPJ:GTIO11 RECORD (Office Copy)
128S_ _ 1n7lF nn4a..,00d_.._N/.S._D1yi`lore
11I: u'T N0. SANITARY DIST. NO. LOT NO. AIIURESS
Re-Model PRoperty Services
PROJECT OWNER JOB SITE PHONE NO.
PERMIT ISSUED Date ELECTRICAL
Bui.ldinp, _ 5125/83 Date Insp.
111ectrical Power Pole_
I'lumhinv Underground --- --
lcchanica.l Rourh Wiring _
'Temp. Gas/Elect. Ua-Fl.s
Solar Ceiling_
Fire S rinkler Fixtures int/Ext _
Sip,,n Notors
Grounding
Misc. Temp. Power _
Other
FINAL. INSPECTIONS Nroved _
Date Insp.
G`s - PLUMBING
F].ectric Date Insp .
Plumbing Backflow _
!lechanical Underground
Solar Underfloor
Pool Partial Rough
Grading Rough Complete
Planni.nl; Solar Rough
Fire Dept . Water & Insulation
Health Dept. Main Drain
Building R/of/S Drain _
Other Gas _
Other.
BUILDING Not Approved
Date Insp.
Pad Certification MECHANICAL
Foundation
- Date Insp.
Pre-Gunite Underfloor S.M.
Slab-Membrane Ducts & Insulation
Bond Beam Fire Dampers
Underfloor Girders Fireplace _
Floor Steel Grease Duct & Hood _
Tiedowns One (lour Shaft _
Diaphrams Condensate Drain _
Seismic Bracing, EquipmenC Anchorage
a].ls-1'ancls Flues & Comh. Air
Frame Other
Lnth Not Approved
Wallboards Int/Ext .
Firewalls
Other
Not Approved
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
s BU LDING PROJECT I DENTI FICATI ON PERMITNUMBER
BUILDING APPLICATION & PERMIT
AD3 2 8 5
DRESS \W1T11 SaT�w
BUILDING -ELECTRICAL-PLUMBING-MECHANI
OWNERS - PLAN CH C TION
ME GTV. ELECTRIC PERMIT FEE
PHONE S
:AME sMA Y 2 $ 1983
ons OUTLETS-SWITCHES-RECEP 5.00/1.00
AME
LIC No. LIGHTING FIXTURES 5.00/1.00 City of Cu
P,ONTRACTOR's APPLIANCES 4.00 Pertino
ADDREss
PHONE PANELS 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER 1
uC no. SIGNS TRANS. 3.00
moo'Ess ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
ADDRESS ADDRESS rs MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00 �/�� [I�
,02 LICENSED CON]RACTORS DECLARATION `G/, Q
M z W I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE ATE
Q Ia (commencing with Section 7000)of Division 3 of the Business and L ELECT. PLG. MECH.
H D i Professions Code,and my license is in full force and effect. ❑ ❑ ❑
z O m - License Class Lie.Number
z r w Datc Contractor
a x � c BUILDING PERMIT
IS 4 OWNER-BUILDER DECLARATION
ao d D INFORMATION
X
; LL as I hereby affirm that I atm exempt from the Contractor's License MISC.- REFER TO ORD
VALUATION $/FT.
H u O a Law for the following reason.(Set,7031.5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requiresa permit to construct,alter,
�W
Q Q ¢Q improve,demolish,or repair any structure,prior to Its 1s5uanel`,aISO ELEC.CONTE, LIC NO. ELEC. (�,� C�
A wG¢ requires the applicant for such permit to file a signed simemenl that TOTAL PERMITTO
>� he i5 licensed pursuant to(lie provisions of the Contractor's License
La >0 Law(Chapter 9(commencing with Section 7000)of Division 3 Of the
3 4 O Business wul Professions Code)or that hcJs exempt therefrom:cod CITY. - PLUMBING PERMIT FEE
M _$ tire basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CCNSTR.
d ; _ by6ny applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 4.00
of not more than five hundred dollars(5500).):
❑ 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 structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not Imply to an owner of
properly who builds Or improves thereon,and who does Sneer work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTALACREAGE
himself m through his own employees,Provided that such improve.
mems are not intended or offered for molded that such
ebuilding GAS-EA.SYSTEM-11NC.4OUTLETS 4,00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 euaowG USE
builder will have the burden of proving that he Aid not build or iso-
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 HES IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with ED ❑ ❑ ED
licensed Contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 AS5ESSO 5PARCEL NO.
and Poilosaions Code,The Cormvctor's 1-icense 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 camractons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ Iumexempt under Sec. ,B.&BC.for this WATER HEATER W/VENT 4.00
reason
Date Owner L WATER SYSTEM - 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COn PENS I' IECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent toself-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,I-ab.C.).
Policy No. Company
O ❑ Certified copy ishcrehy furnished. FIRE SPRINK ENERGY T 24
Z .❑ Certified copy is Bled with file city inspection division. MISC.- REFER TO ORD.
ZO Applicmtt - Y � NC YF] NO '
= W CERTII°ICATEOI'Ii%EMI"PION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.:
W COMPENSATION INSURANCE PLG.CONTE, LIC.NO, PLG.
CL Cl (This section need not he,completed if the permit is for ane TOTAL Y i] .No Y 0 No
0 Z hundred dollars(S 100)Or less.I
U O 1 certify that in the performance of"the work for which this per- GTV MECHANICAL PERMIT FEE FEE SUMMARY
IL I- mit is Issued,I shall not employ any person in any manncrso as to
U become subject to the Workers'Compensation Laws of California.
Date Applicant BUILDING / S�
C. ALTER OR ADD TO MECH. 4.00
} N NOTICI. TO APPLICANT: If,after making this Certificalc of 17x
I.- Z So ption, nu slmuld become Subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provision If the Labor Code, you most forthwith Comply with FEE
U such pro,' , or this permit sha11 be deemed revoked. AIR HANDLING UNIT(TO 10=C,F.M.) 3.00 `
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,00DGFM.) 5.00 SEISMIC FEE (so
I hereby affirm that there is a constructimn lending agency fur 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
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's NAddo,ames ELECTRIC
I certify that l have read this application and stme Omtlhe'above VENTILATION FAN (SINGLE) -3.00
intonation n correct, I agree to comply with all city
truchoand'Unnityrrd PLUMBING
ordinances and State laws a relenting to building construction, and BOILER-COMP I3 H.P.or 100,000 B.S.U.1 4.00
hereby aphorize rcpresmuatives of this city to enter upon (Ire
above-mentioned property for inspecllon purposes, BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, inderanify and eep harmless the Ciiy of MISC.- REFER TO ORD.
Cupertino against liabilities,judsmeni costs and expenses which CONST.TAX
may in any way accrue nguinst saiQ icy in consequenc of he PERMIT ISSUANCE 3.00
granting of til isper tit. MECH.CONT. LIC.NO, MECH.
Z TOTAL
Sign veo phcaat Co ac r Dee TOTAL / dd -
OFFICE COPY