13328i
dip' POST THIS CARD NEAR FRONT OF BUILDING
CITY OF CUPERTINO
INSPECTION DIVISION
JOB INSPECTION RECORD
JOB ADDR ESS �2 ��J - Salem Ave- UNIT# LOT#
'^ C� UNI
OWNER ��'t�,Jl I CONTRACTOR / /Ij�GiS� .I�
PFRMITNUMBE+
PERMIT EXPIRATION
PERMIT EXPIRES IF WORK
IS NOT STARTED WITHIN
180 DAYS OF PERMIT ISSU-
APACE OR 180 DAYS FROM
LAST CAgL'ED,IN�4PECTION.
INSPECTION DATE INSPECTOR
INSPECTION RECORD
FOUNDATION -
07 g�
'
K
UFER —
PREGUNITE
�_��
O
PERMIT vnuDATION
,AU G
Clfy Of Cupertino
% .
ISSUANCE DATE
-
4—NO
P R NCRETE UNTIL ABOVE HAS BEWSRW
UNDERGROUND/SLAB
PLUMBING -
•,
ELECTRICAL
MECHANICAL
BLDG.
ELECT.
PLG.MECH,
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED
,
-
BUILDING PERMIT(; ..
INFORMATION ,
WOOD FLOOR
VALUATION
y�L,
IC 11 000
$/FT.
PLUMBING .�
'�%--
MECHANICAL
ELECTRICAL
ERMIT TO
w
FRAMING
INSULATION 14
STO1
TYPE CONSTR.
4
OCC. GRQUPP
RES, UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF
90 FT, FLOOR AREA
E•"C��r
TOTAL ACREAGE
DIAPHRAGM - -
-
-BUILDING USE
RES IND CON PB Ome,
EX 0 Cl El El
APPLY NO ROOFING U -TIL ABOVE HAS BEEN SIGNED :•
ROUGH
PARCEL NO,
J"t' I'�oW
Lt'
PLUMBING, g'
GAS TEST
'
-
TRACT NO
`dO I
PARCEL NO.
CEL
MECHANICAL �,�7
ELECTRICAL
FINALS ; 'DATE INSP.
ACC.OATE
ACC. FILE NO.
FRAMING -
SAN
INSULATION
PLUMBING
zoNlNc
ENG. SITE No.
GAS
_ Alp
MECHANICAL
ERE SPRINK
v CD N
ENERGY T 24
N0
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED ,HEATING
g;,8
LATH -INTERIOR _ 2
ELECTRICALdq
FLOOD ZONE
Y❑ N❑
AL.U.C.
,
Yo N❑
LATH -EXTERIOR
FIRE DEPT.
SHEETROCK _
GRADE
FEE SUMMARY
SHEAR INTERIOR
BUILDING -
BUILDING
&qS i
SHEAR EXTERIOR •7_ �O-Z-7
TEMPORA Y APPROVALS
FIREWALLS
ELECTRIC -
PLAN CHECK
FEE
GAS
,NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED.
OCCUPANCY
SEISMIC FEE
19 '-
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR.
1
MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505,
IW—� ONE WORKING DAY BEFORE REQUIRED INSPECTION.
O PLEASE GIVE JOB ADDRESS WHEN PHONING.
Z —SEE PERMIT FOR EXPIRATION DATE —
ELECTRIC
1-7> t I,
PLUMeINc
/'0
MECHANICAL
CONST."TAx
IMPORTANTI
PLEASE.READ'REVERSE SIDE BEFORE
CALLING FOR FINAL INSPECTION:.
TOTAL
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
_
APPLICATION & PERMIT
—
BUILDINGELECTRICAL—PLUMBING—MECHANICAL
PERMIT NUMBER
13328
BUILDING
ADDRESS
22—%5 W0n Avenue COT 5
OWNER'S/.lp\
NAME
}�,,�� T�� TT^^^^ (y(4 --r)
Trust 1v LIC. PHONE TIT/t99
OTY. ELECTRIC PERMIT FEE i
PLAN CHECK VALIDATION
NAAMERAcroRs
/to OUTLETS -SWITCHES -RECEP 10.00/1.00
32 LIGHTING FIXTURES 10.00/1.00
Thrust IV Inc, LIG. ND.319115
DATE OF APPLICATION
CONTRACTORS N
ADDRESS
3 DriVe PHONE 969T/722
nAPPLIANCES -RESIDENTIAL 4.00 pO
Z PANELS 16.00 -zo—
ARCHITECT Corp. Arch.
o"
ENGINEER Van A
LF.i � LIC. No.
PANELS 200 AMP) 20.00
PLAN CHEF �E N.C. NO.
SIGNS TRANS. 3.00
AARC OR
DDRESS ENcS3f00
SPECIALCIRCUIT 5,06
sI �R ITfVALI ATION
V JY•
TEMP. METER OR POLE INS. 20,00
Ted Dedriksson ZIP
/ J �W
I \. // /�
(/ N!/
ADDRESSTs
' S Dr. Tht. View
$ MOTORS tSEE,F Fr SCH,
SERVICE CHANGE 2f0.0
LICENSED CONTRACTORS DECLARATION
r r C CII i
I hereby affirm that I am licensed under provisions Of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Coljg Id my license is in full for cL
Licen e.Fly,/„!, 1_ Lic. Numbe 41
Dale �/ T ily Contractor
ISSUANCE DATE
V w'
,,g
f 1 ' `In)
BLDG.
,fir
I Al
IN
ELECT.
PLG. MECH.
\Iu
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DE
1 hereby at drat 1 am exempt from the Contractor's' License
Law forthe following reason.(Sec. 7031.5, Business and ProfessionsPERMIT
Code: Any city orcounty which requires a permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he IS licensed pursuant to the provisions of the Contractor's License
Co. (Chapter 9(commer,ingwith Section 7000)of Division 3ofthe
Business and Professions Code) or thin he is exempt therel'nnhand
MISC. — REFER TO OR
ISSUANCE 10.00 %Qr
`/ V/ALUATION
VV 0
/C vl C)
$/FT.
ELEC. CONTE. LIC. N0.
ELEC. i/L
TOTAL �LJ
PERMIT TO
CITY. PLUMBING PERMIT FEE
STOglES
TYPECONS
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjectsthe applicant to a civil penalty
of not more than five hundred dollars (8500).):
r�i�J+
/�/'�,7/��
ALTER-DRAIN&VENT-WATER(EA.) 5.00
❑ 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 4.00
O C. GR P
RES. UNITS
DRAINS -FLOOR, ROOF, AREACOND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds orimproves thereon, and who does such work
improve-
mems are not finis the
rmcmxfor,or ugh intends or offend forsle. If, ed that however,
or offered for sale. If, however, the but Wing
—I
I
Q. FIXTURES - PER TRAP 5,00
FT. JFLOOR AREA
a�a�.
TOTAL ACREAGE
GAS -EA. SYSTEM OUTLETS 6,00 �'
sold wner
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
builder
prove for purpose of sale.).
❑ as owner of the properly, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RIyEs� IND CON PB Omer
1/dl ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
d
licensed contractors to construct the project (Sec. 7044, Business
License Law does not apply
and Professions Code: The who
to owner of property who builds who
improvesthereon.pursuant
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - ER, A-) 1:06
ASSESSORSPARCEL NO.
-31 1" I a
—O I
tr
contracts for such projects with a wntadorfsl licensed pursuum to
tr
the Contractors License Law.
SEWER IF 200f1/10.00 Al —
TRACT NO.
PARCEL NO. ,
masonO l am exempt under Sec. , B,&1•.C, for this
Quo I , �f
00 4/
WATER HEATER WIVENT 4C1n'7 6.00 —
Owner Date
WATER SYSTEM �(.. U V 5.00 .S �-
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. .. n.F•O 5.00
WORKF-RS'COMPENSAIION DECLARATION
1 hereby affirm that I have a certificate ofconsent to self -insure,
or a certificate of Workers' Com I or o certified
I v ;
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800Lab.C.).ma jL
Policy No. Company
/y
#1MISC.
FIRE SPRINK
v ❑ N ❑
ENERGY T-24
v ❑ N❑
❑ Certified copy isfiled furnished
❑ Certified copy iss filed with the city inspection division.
Applicant
- REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00 16
FLOOD ZONE
A.L.U.C.
PLG. CONTE. - LIC. NO.
TaO,AL �V+ 7
COMPENSATION INSURANCE
(This section need not he completed if the permit is for one
v [:] N ❑
Y ❑ N❑
hundred dollars IS 100) or less.)
I certify that in lire performance o1' the work for which this per.
mit is issued, I shall not employ any person in any manner so as m
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
tlo
y�./
become subject to the Workers Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
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 be deemed revoked.
APPLIANCE 5.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10,000CF.M.) 4.00
AIR HANDLING UNIT (OVER 10PWC.EM.) 6.00
SEISMIC FEE
�a-
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued (Sec.
3097, Cie C.).
MICROFILM
Q HEATING UNIT (TO 100,000 B.T.U.) 6.00
Lender'sName R -T.$-
Lender's Address Rmv 1:iQi��
HEATING UNIT 100,000 B.T.U.)9.50
ELECTRIC
/ C
1�J• 09
1 certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county
Ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 4.00 2—
PLUMBING
I; �a
g01LER-COMPI3P,.1or" OO,000B.T.U.) 6.00
IM
BOILER -COMP (Over 100,900 BTU) SEE FEE SCH.
MECHANICAL
N3
hereby authorize representatives t
this city to enter upon the
above-mentioned property for inspection this
purposes.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
MISC. - .s i(' r "REFER TO ORD.
PERMIT IS UA'NCE Q 10,00 /O—
(�
CONST. TAX
gaiting of this pernmi�t_
MECH.CONT. LIQMECH.
TOTAL ¢� Gib
TOTAL
lja�9?JI�
Signature of Applicant/Conhacmr Dale
OFFICE COPY