2933CITY OF CUPERT',LNO IIISPECTIOU RECORD (Office.Copy)
10300 Torre Ave. ______
PEPdII'r NO. SANITARY DIST. N0. LOT No_ ADDRESS
Fire Sprinkler Modification City of Cupertino
PROJECT OWNER JOB SITE PHONE NO.
PERMIT ISSUED Date II ELECTRICAL
FINAL INSPECTIONS
BUILDIUG
Date
Pad Certification
Insp.
Foundation
Pre-Gunite
Slab-llembrane
Bond Beam
Underfloor Girders
Floor Steel
_
Tiedowns
_
Di.aphrams
Seismic Bracing;
_
I41.1s-Pancls
Frame
Lnth
Uallboards Int/Ext.
Firewalls
Other
Not A> roved
Date
Power Pole
Insp.
Underground
Roul;h Wiring
Partial Routh
Ceiling
Fixtures Int/Ext
tlotors
_
Grounding
_
Temp. Power
Other
_
Not Approved
PLUMBING
Date
Backflow
Insp.
Underground
Underfloor
Partial Routh
P.ough Complete
Solar Rough
Water & Insulation
?fain Drain
_
R/of/S Drain _
Gas
Other
Not Approved _
NECNANICAL
Date
Underfloor S.M.
Insp.
Ducts & Insulation
Fire Dampers
Fireplace
Grease Duct & hood
One (lour Shaft
Condensate Drain
Equipment Anchorage
_
Flues & Comb. Air
Other
Not Approved
,APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
/. BUILDING PROJECT IDENTIFICATIONP
APPLICATION & PERMIT
ER
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AOnPE
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BUILDING -,ELECTRICAL- PLUMBING - MECHANICAL
J
OWNER'6
PLAN CHECK VALIDATION
NAME
c17o F C& ' r . P.ONE Zg 2
CITY. ELECTRIC PERMIT FEE
NgMERa rolls -
OUTLETS - SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
LIC. NO
CONTRACTORS
NRAC
A EGRESS
APPLIANCES -RESIDENTIAL 4.00
- 5.00
119 2-143.1WI 4- PHONE:LI:53PANELS
DATE OF APPLICATION
ARCHITECT
ENGINEER
%Trd LIC. No 15A Jil(a
SIGNS 6.00
PLAN CHECK FEE
SIGNS TRANS. 3.00
ARC.E R ENG'
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
7EMP. METER OR POLE INS. 15.00
ZIP
�\
APis
REss '
AoDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under Provisions ol'Chapter 9
(commencing with Section 7000) of Division 3 of the Business anti'
Professions Cod 'Ind I license is is full for�r yrs{ �ecj. /
License CISs Lic. Number.�Di1.Q=T�
ISSUANCE DATE
BLDG.
ELECT.
❑
PLG. MECH.
❑ ❑
_
Uate �L'Ontract or
OWNER -BUILDER D17CLARAT'ION
I hereby affirm that I am exempt from the Contractors License
Law for the following reason. (Sec. requires
a, Basin essand Prufessio alter,
Code: Any cityor eau my which requires a permit Loco issuance. also
improve, demolish. Or repair any structure, prior to its ISSOanef. lllSV
requires the applicant for such permit to file a Signed statement that
he is licensed pursuunl to the provisions of lire Contractor's License
Law (Chapter 9(commencing with Section 7000) of Division 3 ofthe
Business and Professions Code) or that he is exempt therefrom and
BUILDING PERMIT
INFORMATION
MISC. - REFER TO ORD
vA LUATION
$/FT.
PERMIT ISSUANCE 6.00
ELEC. CONTE. LIC. N0.
•
ELEC
TOTA.L
PERMIT TO QaF'{�
J
CITY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant lot a pemlit subjects the applicant to a civil penalty
of not more than five hundred dollars ($500).):
ALTER -DRAIN -WATER (EA.) 4.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will Jo the work, and the structure is not
BACK F LOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, COND. 4.00
intended or offered for sale (Sea 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner o1'
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve.
mentsarenotintendedorofferedforsale. If, however, the building
FIXTURES - PER TRAP 4.00
SO, FT. FLOOR AREA
TOTAL ACREAGE
-
GAS-EA.SYSTEM-11NC.40UTLETS 4,00
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 of sale.):
Cl.
1, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 1.00
BUILDING uSE
RES Irv0 CON PB Octel
❑ ' ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 2000
licensed contractors to construct the project (Sec. 7044, Business
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 -I INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts forsuch projects with a contortions) licensed pursuant In
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ lam exempt under Sec.-, BAP.C. for this
reason
WATER HEATER W/VENT 4.00
Date Owner
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORK F.RS'COMPENSATION DECLARA TICK
I hereby affirm that 1 have a certificate of convent to self-insu c,
m a certificate of Workers Compensation Insurance. Or a certified'
ZONING
ENG. SITE N0.
colic thereof (Set. LAC.).
Policy No. CComp.mpany
❑ Certi' opy is hereby Runish cd.WPnsp OF
❑ Certi'e copy s 1' wlDl thL inspection division.
Applicant
FIRE SPRINK
Y❑ N❑
ENERGY T44
Y❑ N❑
MISC.- REFER TO ORD.
CF: IFICATE OFEXIiM� WORKERS.
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.O.
PLG. CONTE. LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE
(This section need .not be completed if the permil is for one
Y ❑ N ❑
Y ❑ N ❑
hundred dollars IS 100) or less.)
I certify that in the performance of lire work for which this per-
mit is issued, 1 shall not employ any person in any rammer sn as to
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
�
d AV-
become subject to the Workers' Compensation Laws of California.
Date ApplicantALTER
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
NOTICE
OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
emption, you should become subject to the Workers Conlpmleation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10=CF.M.) 3.00
AIR HANDLING UNIT (OVER IOpWCRM.) 5.00
SEISMIC FEE
CONSTRUCTION L17NDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
the performance of the ..,it tnr which this pemlit is issued (Sec.
3097, Civ.CJ.
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATI NG UN IT (OV ER 100,000 B.T.U.)7.50
ELECTRIC
Lender'sNume
Lender's Add, ess
VENTILATION FAN (SINGLE) 3.00
PLUMBING
I certify tlim I have read this application and swte tbut the above
information is correct. I agree to comply with all city and county
ordinances and stale laws relating to building ecom,uction, and
BOILER-COMPI3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100.000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purpose%.
MISC. - REFER TO ORD.
CONST. TAX
(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
PERMIT ISSUANCE 3.00
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
grandpg of this permit
✓IM F�QSjI� ►�-t�-s�
Signature of Applicant/Contra or Dute
OFFICE COPY