6681CITY OF CUPERTINO INSPECFION RECORD
(OFFICE COPY)
ADDRESS
OWNER
Pad
FINAL INSPECTIONS
BUILDING
:,bear nt xt. -
Fire a1 s
DATE 1 INSP
PLUMBING DATE
ELECTRICAL
INSP.
DATE INSP.
Not pn>ved— _�
:APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
,I BUILDING PROJECT IDENTIFICATION
'
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMITNUMBER
' 6681
..CEDING
ADDRESS
5NGREEfL BL.0
. 190Z �,�'3
NAME Lam/) Ib (a •D��. �., r
• PHONE SIV/ �1'�
_
ELECTRIC PyE_RMIT FEE
.• ,% 'f:,S I .'n
PLAN CHECK VALIDATION
CONTRACTOR'S
NAME
JD UTLETS-SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
L.C. NO.
AC
DNTH DRESS ons
A - -
ADDRESS -
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
PHONE
1 DATE OF APPLICATION
ARCHITECT
.OR �lzEir ��
ENGINEER
LIC. No.
SIGNS - 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH, to ENG. �/G / NJ r�S1
ARCHE R JeJ V IV /�
ZIP1950.90
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS.
AR
ADDDDRESSESS
MOTORS - SEE FEES
r
7
SERVICE CHANGE P 10.
LICENSED CONTRACTORS DECLARATION
I Cutesy aft Ihn[ 1 um licensed under provisions of Chap[er 9
(commencing with Section 7000) of Division 3 of the Business and
I'rofmines Code, and my license is in full force and effect
I ATE
BLDG. ELECT. PLG, �.,1¢CH.
�, L+ .
/fj/ of
CIO
I.1cemo Class Lic. Namher
❑
Dam Contractor
OWNER- ;izn ex iit DECLARATION '
I hereby affirm Thal I :nn exempt tom the Contractor's License
Law forthefollowingreason..(Sec. 7031.5, Business and Professions
Code: Any city oreganly which requires a permit to construct, alter,
improve,demolish, orrepairany structure, prior to lSlSSmmCC,alSO
requires the applicant for such permit to file if signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Divisimi 3 of the
Business and Professions Code) or that he is exempt therefrom and
BUILDIN i
`f4'". WFORM_A IONtIR' ?�..
-'-- - -
MISC. - REFER TO ORD
PERMIT ISSUANCE 6.00
VALUATION g/FT.
ELEC. CONTR. LIC. NO. ELEC.
- TOTAL
qy, PLUMBING PERMIT FEE
PERMIT TO
'
�EM l/QEL
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant pan civil penally
of not more than five hundred dollars ($500),1:
�(
STORIES
TYPE CONSTR.
g
ALTER -DRAIN & VENT -WATER (EA.) 4.00 O
❑- 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
V DRAINS -FLOOR, ROOF, AREA, COND. 4.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: 'Phe Contractor's License Law does not apply to an owner of
III PIXTURES - PER TRAP 4.006 •^'
GAS-EA.SVSTEM-11NC.40UTLE7$ 4.00 --
property who builds or improves thereon; and who does such work
himself or through his own employees, provided that such improve'
memsare not intended or offered for sale. If, however, the building
SO. FT, FLOOR AREA
TOTAL ACREAGE
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,
prove for purpose ofsale.).RES
M L as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 1.00
BUILDING USE
IND CON PB Other
❑ 0 D D
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
LAWN SPRINK VER 5 (EA.) 1.00
licensed contactors I.'consDuct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
town owner of property who builds or improves thereon, and who
ASSESSORS PARCEL NO.
contracts for such pn.j"t, with if contmetods) licensed pursuant to
the Contractor's License Lxw.
❑ I am exempt u d' Sec. ,BAP.C. for this
reason
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO,
PARCEL NO.
WATER I/J/V 4.00
Owner � -rDate -
WATER SYSTEM4.00
ACC. DATE
ACL. FILE N0.
WATER IW4AIFf 4.00
WORKERS'COMPI'NSATION DECI.ARA'rION
I hereby affirm that I have a certificate of consent m self -insure,
ZONING
ENG. SITE NO.
or o certificate of Workers' Compensation Insurance, or a certified
copy thereat (Sec. 3800, Lm.C,L
-
Policy No. Company
❑ Certified copy is homy furnished.
❑ Certified copy is fled with the city inspection division.
Applicant
MISC.-. REFER TO ORD.
FIRE SPRINK
Y [D N[_
ENERGY TZ4
Y [] N�
CERTIF'ICAT'E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Phis section need not be complete,] if the permit is for nice
PERMIT ISSUANCE 6.00
FLOODZONE
Y E] N[]
A.L.U.C.
Y N
PLG. CONTR. LIC. NO.
PLG. (,
TOTAL 7Q
hundred dollar, ($100) or less.) -
I certify Out h the performance of the wink for which This per.
mit is issued, I shall not ,forma any person in any manner so as In
�T y MECHANICAL PERMIT u FEE
\7r) -
FEE.SUMMARV.''
A �"
BUILDING
�j
become Subject to the Workers' Compensation Laws of Califomia.
Date Applicant
ALTER OR ADD TO MECH. 4.00
NOTICE 'r0 APPLICAN"I': If, after making this Certificale of Ex-
APPLIANCE 4.00
AIR HANDLING UNIT (TO 10,030C.F.M.) 3.00
PLAN CHECK
FEE
emption, you should become subject Co [lie Workers'Compensation
provisions of the A.abor Code, you must forthwith comply with
such provisions., this per... it shall be deemed revoked.
CONs'rRUCTION LENDING AGENCY
AIR HANDLING UNIT (OVER 10p00GEM.)5.00
SEISMIC FEE
NOD
EXHAUST HOOD (WITH DUCT) 2.00
I hereby affirm that Isere is a construction lending agency for
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
Lcndcr'sAdduss
HEATING UNIT 100,000 B.T.U.)7.50
ELECTRIC
/-
J ��
VENTILATION FAN (SINGLE) ' 3.00
1 certify thud I lave read this application and state Chat the above
information is correct. I agree to complyawith all city and county
mdrem.s and stare laws relating to building construction, and
hereby authorizeroperty tarries of This city to color upon the
hereby above-mentioned property for inspection purposes.
PLUMBING
'
BOILER -COMP (3 H.P. or 100,000 B.T.U.) 4,00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
(We) agree to save, indemnify and keep harmless the City of
Cupert' o against liabilities, judgments, costs and expenses which
may icy w y accruago. t said City in consequence of lire
gra in of Ih' m I
d B�TOTAL
MISC. - REFER TO ORD.
PERMIT' ISSUANCE 3.00
CONST. TAX
MECH. CONT. LIC. NO.
MECH.
TOTAL,
��oLQe
Signature of Applical /Contractor ate
OFFICE COPY