4993 CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
PERMIT, O. D REbti LOT NO..
i Sn I�yiy V ��y�l c l Vf/1(lc0UwN�
PERMIT ISSUED DATE "ELECTRICAL DATE INSP.'
Fe
c
Plumbing Power Pole
Mechanical er oun
Te as ec ou irm
So ar Walls .
ire rin cler Ceiling
ixtures Int/Ext
otorFr s
Misc. Grounding
Tempmower
Other
FINAL INSPECTIONS DATE INSP, Not rove -
Gas
Electric
Plumbing PLUMBING DATE INSP.
Mechanical
volar Backflow
Doler oun
Grading er oor
Planning Partial Roug
Fire Dept. Aou�i o Tete
ea 1t ept. o ar ou
I3uijdin Water ', Insulation
Other in ain
770777ain
Gas
,Other
BUILDING DATE INSP, Not rove
Pad Certification
oun ation ELECTRICAL DATE INSP.
re- unite
a - Nem rane Underfloor S.M.
Bond eam cts nsu ation
Underfloor Girders Fire loDan ers
or feel ire ace
ie owns Grease Duct oo
is ramse our Shaft
eismec Bracing Condensate rain
walls- anels �ipment Anchorage
Frame 3 - Flues , Comb. Air
zt Ot er
1 5oar xt, of rove
Firewa s
OtFe—r -
Net Approved
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
AUONE U• - _ /'JS� APPLICATION & PERMIT 4993
Ns
�. /baspa �I\ BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S C•V PLAN CHECK VALIDATION
NAME /A �(T' OTY. ELECTRIC PERMIT FEE
c PH0NLZs3 • S
CONTRACTORS OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
LIC..O. LIGHTING FIXTURES 5.00/1.00
CONAe7oR's
ADDRESS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECT77 P.C.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCHON ENG. SPECIAL CIRCUIT S,QQ PERMIT VALIDATION
AODRESS
IIP TEMP.METER OR POLE INS. 15.00
AvvucANrs - MOTORS SEE FEE SCH. J
APPLICANTS
SERVICE CHANGE 10.00 r�
woo LICENSED CONTRACTORS DECLARATION ✓/�/
a v I hereby affirm Ola( I am licensed audit,provisions of Chapter 9 ISSUANCE DATE
N a N (conuneacing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F D Z/ Pmfessiuns Code,and my license is in full force and effect. ❑ ❑ ❑
z o H License Class Lic.Number
0 z r 0 Date Contractor L ILDING PERMIT
a w a OWNER-R-BUILDER DECLARATION V - ORMATION
A o A U MISC.- REFER TO ORD
w ; n I hereby affirm that I am exempt from the Contractor's License VALUATION $fFT.
F a_o j Law far the following reason.ISec.7031.5.Business and Professions PERMIT ISSUANCE 6.00 f.J
Code:Any city or county which recur...a permit to construct,alter, fvptiw�'1��•
a p improve,demolish,or repair any structure,prior to its issuunce,also ELEC.CONTR. LIC.NO. ELECT, YT'IIDa�
ar
O u requires the applicant for such permit to file a signed statement that TOTAL PER
a w m he is licensed pursuant to the provisions of the Contractor's License
Fri Law(Chapter 9(commencingw'ith Section 7000)of Dlvision3ofthe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE ��
szD
Or F o the basis for tire.))egcd exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; m by any applicant for a permit subjects the applicant to a civil ociaIt
y gLTER-DRAIN -WATER (EA.) 4.00
of not Inure than live hundred dollars(8500).):
❑ 1,as owner of tire property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCG 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 apply,to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 so.FT.FLOOR AREA TOTAL ACREAGE
himself re through his awn emred for sale.Prrvid ed thus such imprrve-
mmself o notintcodedorof(.red for uvid,d that suhebu0ding GAS-EA:SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion, .the owner- GAS-EASYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did nut (lie'
or int- RES IND CON PB Omer
prove for purpose ofsalc.). INDUSTRIAL WASTE INTER. 20.00 E:1 ❑ ❑ ❑ 1:1❑ I,as owner of the property,ton exclusively contracting with
licensed contractors to construct the project(Sec. 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code,'I'hc Contractor's License Law docs 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 contmstots)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the C.Prif"or's License Law.
❑ Ian.cxemptundcr Scc ,B.&P.C.Ii..this WATER HEATER W/VENT 4.00
naso
Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKIiRS'COMI iNSAI'ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a celliticute of consent h "elf-insure ZONING
or a certificate of Workers'Compcmation Insurance,or a Certified ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Qnnpany
O ❑ Certified copy is he,cby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city impection division. - MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ No
OApplicatit
CERTIFICATE OP EXEMPTION PRO.,\1 WORKIiRS, PERMIT ISSUANCE 6.00 FLOOD 20NE A.L.0 L.U.C.
W > CO,\IPIN$e\TION INSURANCE PLG.CONTR. LIC.NO. PLG,
d 0 ('Phis section need not be completed if lire peril is for one TOTAL Y❑ N❑ v❑ N❑
Z) Z hundred dollars(S 100)or less.)
U O I certify that in the performance of tire work for which Iris per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issmd, 1 shall not cmPlcy any Pcrfan in any'manner ser as to
Ow become subject to the Workers'Compensul ion Laws of Calitornia. BUILDINGrb
Date ' Applicant ALTER OR ADD TO MECH. 4.00 g3.
} w
N01 IC- '1'O APPLICANT: If,after making this Certificate of Ex-
? enhption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such pnmisimrs or this permit shall he dccnwd revoked. AIR HANDLING UNIT(TO 10)WOC.F.M.) 3.00
CONS"f RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.15.00 SEISMIC FEE
�,•�V
1 hereby affirm that (here is a construction lending agencv for EXHAUST HOOD (WITH DUCT) 2.00
the perionf ance of the work for which this permit is issued(Sec.. MICROFILM
3097,Civ.G). HEATING UNIT(TO 100,000 B.T.U.1 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lcndcr's Address
I artily um(I have read this application and state)hal the above VENTILATION FAN (SINGLE) 3.00
mf.rnwlion is correct. I agree to comply with all city and county BOILER-COMP13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction. and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to sivc, indemnify and keep harmless the City of MISC.- REFER TO ORD.
'Cupertino against lis ' 'udgmcuts, costs anti expense,which nPERMIT ISSUANCE 3.00 CONST.TAX
ay in any way u nL agar _ said City in consequence o1'thc
S
ofranlin this p n '. MECH.CONT. LIC.NO. MECH.
Z _bs TOTAL TOTAL L 'Sol
nature of A ican/ ontractor
OFFICE COPY