5217CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
17
�.
PROJECT OWNER
FINAL INSPECTIONS DATE INSP,
Gas
ELECTRICAL DATE JINSP.'
Power Pole
Underfloor S
ELECTRICAL DATE I INSP.
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTI FICATION.
APPLICATION& PERMIT,
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
5217
ADDRESS
a°"°'"° s
OWrveR' /] 'a
NAMF Q /_ F � ✓• Pt 1 ^
PRONE2 {J-
A' 'p$ ! •
i' 1. �y 4. r H A ae(, h i. .}'A,.r�: {r".
OTV., a • ELECTRIC PERMIT FEE'
PLAN CHECK VALIDATION
,
NAME crORs
NAM[
OUTLETS - SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
' LIC. NO.
OOT AHCTOR's'
AOOR AC
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
PHONE
DATE OF APPLICATION
ARCHITECT
OR
ENGINEER
d b ZcP, UC. NO,eDA
SIGNS 6.00
' 'PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH, OR ENG.
A,/o�REssn /
b( 8 _/� d F ' zIP
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00
APPLICANT••
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSLO CON'T'RACTORS DECLARATION
-
I hereby affirm that I am licensed under provisions ol'Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code ' ,anl"vnse is in full force
Licensee C��Inna's^ Llc. Number_ �_/��
Date 11 /IZ ContractorlLa/_1-Lr,-
,1/ OWNER -BUILDER DECLARA'I'[ON Ems, W
IS ANLENLE D
L G. E ECT. PLG. MECH.
BUILDING PERMIT,i'
MISC.- REFER TO ORD
'
I hereby af0rm than I am exempt from the Contracmr's License
Law for the foilowingreason.(Sec. 70.11.5, Businessand Professions
Code: Any city or county which requires a permit to construct, antes
improve, he applies or repair h p sticture, prior Co its issuance, also
requires the applicant foo such permit l0 file a signed statement That
he is licensed pursuant to the provisions of the Contractor's License
INFORMATIUN'pu.'J;,
PERMIT ISSUANCE 6.00/
"/ALUATION S/FT.
�OO
ELEC. LDNTn, LIC. NO. ELEC.
TOTAL
PERMIT TO
of Division 3 of the
Law (Chapter 9 (commencing with Section is exempt
Business and ProfessionsCode)xempt or That he is exempt therefrom and
QTY: �- PLUMBING PERMIT FEE'
v C' I
the basis the allegedexem exemption. Any violation of Section 703L5
STORIES
TYPE CONSTR.
byany tn'or icaantiveiundresubject ($50the pplicanttoacivil penalty
applicant
nl not more than five hundred donors (my um1:
❑ Las owner at the property, or my employees wish wages as
their sole compensation, will do the work, and the structure is not
- S. C
ALTER-DRAIN&VENT-WATER(EA.)4400
BACK FCOW,PROTECT. DEVICE 2,Q0
OCL. GROUP
RES. UNITS
ROOF, AREA, GOND. 4,00
intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,
Code, The Contractor's License Law does Lou apply to an owner Of
property who builds or improves thereon, and who docs such work
himself or through his own employees, provided that such improve-
mentsarenotintendedorofferedforsale. D', however, the building
FIXTURES - PER TRAP 4.00
SO, FT. FLOOR AREA
TOTALACREAGE
GAS - EA. SYSTEM - I INC. 4 OUTLETS 4.00
)r innprovemem is sold within one year of completion, the owner
builder will have the burden of proving'that he did not build or UI
Prove for purpose of. the
❑ L as owner of the property, am exclusively contracting with
GAS
GAS - EA. SYSTEM OVER 4 (EA.) 1.00
BUILDING USE
IND CO PB Other
❑ ❑ \❑ ❑
INDUSTRIAL WASTE INTER. 20.00
licensed contractors In construct the project La 7044, ofap Business
The Contractor's License Law doesnotapply
and frowner of
to an owner of property who builds or improves thereon. and who
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
ASSESSO CEL NO.
contracts lot such projects with a contractonsl licensed pursuant to
the Cmu.,mr's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO,
PARCEL NO.
❑ Iamexemplunder Sec , 134P.C.forliis
reason
WATER HEATER W/VENT 4.00
Owner Date
WATER SYSTEM 4.00
ACC. DATE
ACC, FILE NO.
WATER TREATING EQUIP. 4.00
WORK ERS'COMPENSAT'ION DECLARATION
1 hereby affirm that I have a certificate )(consent to self -insure,
or a certificate of WorkersCompensation Insurance, or a certified
ZONING
ENO. SITE NO.
copy theraof(Sce. 3800, Lab.C.).
Policy No. Company
FIRE SPRINK
V N
❑ ❑
ENERGY T -Z4
V N
❑ ❑
❑ Certified ro py is herchy funakin d.-
LCn'tili It" d ith IT c' i...Peclion division.
MfIIY °
MISC.- REFER TO ORD.
r
CER'1 ICA'I'I? OF IiXIi ON AROMWORKeRS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A. L. U.C.
COAIPENSA NINSURANCE
Cfhis action need not be completed if the permit is for one
y ❑ N❑
V ❑ N❑
PLG. CONTR. LIC. NO.
PLG.
TOTAL
hendred dollars (S 100) or less.)
certify That in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner So as to
CITY MECHANICAL PERMIT - FEE
^ FEErSUMMARY,t
re #�F
-
BUILDING
dD
�O-_1
becomesuhjecttotheWorkers'Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 4.00
NOTICE '1'O APPLICANT: If, after making this Certificate of lix-
APPLIANCE 4.00
AIR HANDLING UNIT (TO 10=C.F.M.) 3.00
PLAN CHECK
FEE
/ 33
emption, you should become subject to the Workers' Compensation
provisions.of the Labor Code, you most forthwith comply with
such provisions Or this permit shall he deemed revoked.
AIR HANDLING UNIT(OVER 10000C.F.M.) 5.00
SEISMIC FEE
,fv
CONS "rRUCfION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
the perl'ormance,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
H EATI N G UN IT (OV ER 100,000 B.T.U.)7.50
ELECTRIC
I certify that I have read this application and slate that the above
VENTILATION'FAN (SINGLE) 3.00
information is correct. 1 agree to comply with all city and county
ordinances and state laws relating in building construction, and
PLUMBING
BOILER- COMP (3 H.P. Or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100.000 BTU) SEE FEE'SCH.
MECHANICAL
hemby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify an cep harmless the City of
Cupertino a St liabilities, judgman ,cast and expenses which
may in n ago' t sai ity' wase Ince of the
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 3.00
gmnti f p h
MECH. CONT, LIC. NO. MECH.
III! r/zTOTAL
TO,T.AL '
S' [ o APP icantlCo for D
61 OFFICE COPY