9955 CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY
P.lti(lXjy/ L� viOe_ � L✓- 5
PROJECT UrNER
PERMIT ISSUED DATE , / "ELECTRICAL DATE INSP:
Building `/
E' e� ctrica
PluTib
ing Power Pole
Mechanical er oun
Temp as ec ou iron
o ar Walls
Fire Sprinkler e in
bign fixtures Int/Ext
otors
Misc. Groundui
e ower
Other
FINAL INSPECHONS DATE INSP, Not :Approved
Gas
Electric 3:
f-
Plumbing PLMIBING DATE INSP.
.Mechanical
ar Backflow
Jo e ��
Grading er oor
ann�nPartialou
Fire pt. offo ete
Health e t, Solar RoHgh
Building 3 . ater '$ Insulation
Other Main Drain
R/of/S Drain
as
Other
BUILDING DATE INSP. Not rove
Pad Certification
oun ation ELECTRICAL DATE INSP.
re- unite
Slab-Niembrane Underfloor S.M.
Bond eam Ducts & Insulation
Undertloor Girders Fire D ers
Floor Steel Fireplace
ie owns Grease Duct 4 Hood
iap rams e ' our Sat "
teismec Bracing on ensate Drain
Walls-Panels E ui ment Anchorage
rame —2q Yv Flues & Comb. Air
1�t t er
a oars nt xt. of 7FProved
Firewa s
Other
Net Approved
/f.PPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
eDILDING APPLICATION & PERMIT 4955
ADDRESS
'.JEM"v 6vDL FQ RO BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S '� PLAN CHECK VILIDATION
'AMC -72'S Db 0(0 CITY. ELECTRIC PERMIT FEE PAW
Ji M S PHONE p
ONreacroRs UTLETS-SWITCHES-RECEP 5.00/1.00
WAME _ rp 1 •� '�gpa
NGD 1
��(}•y[. CSN SiX.✓<:70e✓ $d2-3i 6
ucNo. LIGHTING FIXTURES 5.00/1.00
.
?(
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS °{ Cupervi°0
� yC1
3 Lf(5- Sk LL-M} ✓ISl} ,E 24113-70 PANELS 5.00 GAME
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.no. SIGNS TRANS. 3.00
ADENc' SPECIAL CIRCUIT 5.0D PERMIT VALIDA ION
ADDRESS
ZIP rrEMP,METER OR POLE INS. 15.00 I
APPLICANTSMOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
o a LICENSED CONTRACTORS DECLARATION
U u I hereby affirm that I am licensed under provisions of Chapter 9 N EDA
a n ¢rommencing with Suction 7000)of Division 3 of rhe Business anA aLD G. MECH.
r Professions Code,' d my license is in full farce and efl'c`I. +
z O w License lass�gp� Li,.Number 'S_ s! 1 f I ❑ ❑
o F pate (= Contractor
wa777Q OWN13R-BUILDER DECLARA'f1ON B FORMDING PERMIT
w REFER TO ORD NFORMATION
wLL H 1 hereby affirm)hal I am exempt from the Contractor's License MISC.- VALUATION S/FT.
L 0< Law forum following reason,(See.7031.5.Business and Professions PERMIT ISSUANCE 6.00 / 000
Code:Any city or county which rcynires a permit to construct,alter
K Q improve,denmlish,or repair any drucwm,prior to its iYsumlce,also ELEL.CONTR. LIC.NQ ELEG 04
DLL requires till'applicant for Fedi permit to file u aved stliculent)Ilei TOTAL // PERMIT TO
ww he is licensed pursuant to the provisions of the Cont rector s License �F
oa z i Law(Chapter 9(commencing with Section 7000)of Division 3 of the
14 o Business and Professions Code)or that he isexmnpt therefrom and OTY. PLUMBING PERMIT FEE
at r Ci the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d; _ by any applicant for a permit subjuels the appllcantto a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500).1:
❑ I,Towner of the property,or my employees with wages asggCK FLOW PROTECT. DEVICE 2.00 sec.GROUP RES.ON''a
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 docs not apply to all owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 s0.Fr.FLOOR AREA TOTALACREAGE
• e
mntsf m through his own employees.Provided that such improve-
ents are not intended or offered for sale.IL however,the building GAS-EA.SVSTEM-11NC.4OUTLETS 4.00
or improvement 1s sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or hit.. GAS
IND CON PB Othxr
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 El F-1 El El 1:10 1,as owner of the property,am exclusively'contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 5,00 ASSESSORS PARCEL NO.
and Professions Coir:The Contractor's License Law does not apply
1.an owner of property who builds or impulses,thereon,and will, LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts lin such projects with a contractimo licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200108.00 TRACT NO. PARCEL NO.
O I and exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 4.00
reason
)are Ow ne, WATER SYSTEM 4-00 ACC.DATE ACC.FILE NO.
WORK FRS*COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure,
ENO.SITE NO.
in a certificate of Workers'Compensation Insurance,or a«rtldflcZONING
copy thereof(,Sec.3800,Lab.C.).
P.HEY No. Company
Q ❑ Certified copy Is hereby'furnished. FIRE$PRINK ENERGY Ti4
Z z� ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. y❑ N❑ Y ❑ N❑
F :`5;\ Applicant
CC h CIiR'fl1%CATIi OF EXIiMBI'ION PROM W'oRKIiRS' PERMIT ISSUANCE 6.00 FLOOD ZONE .ALU.L.
IL > COhIPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL ❑ (Thio ,titin Cecil ,of be conpleted if the permit is I., one - TOTAL' Y❑ N❑ Y ❑ N❑
D Z hundred dollars IS 100)or less.I
U O 1 certify that in the performance of the work for which this Per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued.I shall not employ any person in an Canner so as to
O U become subject to the Workers' Ipe utl nl6 ...f Ca'i,mmia. BUILDING /7
U0. utc?-E ^&N Applicant 'K A� ALTER OR ADD TO MECH. 4.00
} Do NOTICE 'I'O AI'I'LICAKf. II,after slaking This Certificate of Bx-
F2 colprion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such Previsions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE SO
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ CA HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT IOVER 100,000 B.T.U.)Z50 ELECTRIC
Lender i Address
I certify that I have read this application and stare that the above VENTILATION FAN (SINGLE) 3.00
• information is correct. I agree to comply with all city and County PLUMBING
srrh ner, and state laws relatingO
to building consuction. :rad BOILER-COMPI3 H.P.or 100,000 B.T.U.) 4.00
hereby uutlnriie representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-nanf Toned property for inspection purposes.
(we) agree to save, indenmily and keep harmless it,,City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and oxpenscs whidl CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
anling of this per it. MECH.CONT. LIC.NO, MECH.
Y1n...?7Cn J �'E�
TOTAL TOTAL S�
Signature of Applicant)/Contractor Date
OFFICE COPY