6239 (2) CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
1ADDRESS LUr NO.
PERMIT ISSUED DATE ELECTRICAL DATE INSP
Fuin
ecittica
PlunbinjZ Power Pole
eFfTianical r un
e as ec u irin
Solar INalls
Fire Sprinkler 1 In
1 ixtures nt xt
tors
Misc. Grounding
e ower
Uther
FINAL INSPECTIONS DATE INSP, Not rove
Gas
Electric
.Pl—umBin.Q PLUMBING DATE INSP.
.mechanical
•oar Backflow
ool Underground
Grading oor'
Planning Partial ou
ire a t.
Rough o ete
ea t t. solar Kougb
ui ing ater ' nsulation
Uther ain
o am
Gas
Other
BUILDING DUE INS, p of Approved
Pad Certification
Foundation ELECTRICAL DATE INSP.
Pre-Gunite
slab-Membrane Underfloor S.M.
bond Beam M-EMFT7nsulation
Underfloor GirdersFj ers
Floor tee i re ace
ie owns brease Duct & Hood
Diaphr� One Hour— t
eismecracin Condensate rain
Walls-PaneTF
went An rage
Frame Flues r
Lath Me-
&; oar Int/Ex-t. of rove
irewa s
other
Net Approved
APPILICANT,TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY.
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
apILDING . APPLICATION & PERMIT.
ADDRESS ' /�/"N/�
r
[BUILDING -ELECTRICAL-PLUMBING-MECHANICAL IU_ G JJ
WNER'e 2s r,. PLAN CHECK VALIDATION,
N _
PHONE PS TY• ELECTRIC PERMIT FEE '
c AZE croRs OUTLETS SWITCHES-RECEP 5.00/1.00
rv0.�� �' LIGHTING FIXTURES 5.00/1.00-
C NTH CTO
AD HESS +� PPLIANCES-RESIDENTIAL 4.00 -
PHONE' 7tp PANELS 5.00
ARCHITECT DATE OF APPLICATION ,
OR SIGNS 8.00 PLAN CHECK FEE ^RO NO.
ENGINEER' I
uc.No. abd SIGNS.TRANS. 3.00 1.
ARCH,OR ENG ` "
AOOgEas' P SPECIAL CIRCUIT - $,OO PERMIT VALIDAT N
GVH nP - EMP.METER OR POLE INS. 15.00 '
AAPDPucgrvrs _ MOTORS SEE FE SCH.
s s I�
SERVICE CHANGE 0.00 lO/�' /
0 0 0 LICENSED CONTRACTORS DECLARATION
<i w I hereby affirm that 1 am licensed under provisions of Chapter 9 i ISSUANCE DATE
a,a N (commencing with Section]000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F_w z Professions Co an icensc is in full fort•' ff-�[
z o m - License Cf
C.
_ + Lic.Nambe ❑ ❑ ❑ ❑
,Z,r H Dote Contractor_ /
¢ yf II
¢ ¢ w ¢ OWNER-BUILDER DECLARATION
BUILDING PERMIT
U INFORMATION
go
X ;LL N 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u O¢ Law for the following reason.(Sec.7031.5,Business and Professions VALUATION
LUATION $/FT.
Code:Any city or county which requires apermitmconslrucLalteq PERMIT ISSUANC " ' 6.00 oOo
¢ ¢ Q 0 improve,demolish,or,Spar'any sheet ure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. -
¢ requires the applicant for such Permit to file a signed statement Iha[ ELEC
a w m m he is licensed pursuant to the provisions of the Contmemr's LicenseTOTALPERMIT TO
H z a Law(Chap'er9(com men ting with Secllon]000)of Division3of the
T D Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE '
¢ H m the basis for the alleged exemption.Any violation of Section 703 LS 5T IEB TYPE CONSTR. -
d3 - by any aor..lim for
permitsubjecrs'he applican'toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than flue hundred dollars(5500).):
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE
It it sole Com penComm,will d0 the work,and the shuc[ure is not 2.00 OCC.GROUP RES,UNITS
Code eFi or'anR`offered for sale(Sec. doe' Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 '
Code:'the h onlmd or License Law does not apply fo an insof
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP "4.00 SO.FL FLOOR AREA TOTgL ACREAGE
himself or through his own employees,provided that such improve
men's are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 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- GAS-EA.SYSTEM-OVER 4(EA.) 1,00 BUILDING USE
Prove C'el, s Ownerpurpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND " CON FB Omer
❑ L as owner of the property,he exclusively contracting with 0. O O 11
licensed contractors to construct the project(Sec.7094,Business LAWN SPRINKLERS-1 INC 5 V.B. _
and Professions Code:The Contractors License s th does not apply 5.00 ASSESSORS PARCEL NO.
to tracts o of property who builds tr improves thereon,sua who LAWN SPRINKLERS-OVER 5(EA.) 1.00 - L
contracts for such projects with u conlractorts)licensed pursuant to. -
the Contractor's amexemptense Sec, SEWER-SANITARY-STORM EA.200ft/8.00 rRACTNO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this
reason WATER HEATER W/VENT 4.00
Owner Date *PERAN
11
-
4.00 ACC.DATE ACC.FILE NO.
WORKLRS'COMPENSA"PION DECLARATION TREATEQUIP. 4.00
I hereby affirm that 1 have a certificate ofeonsent to self-i ohne,
or a certificate of Workers:Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.CJ. - '
Policy No. Company.
Q ❑ Certified ropy is hereby famished FIRE SPRINK ENERGY T2A
Z Z K Ccrb d copy is wjt- tb`y�y inspca�I�p di . .Applicun /1r wa. REFER TO ORD. YC] N Y❑ NE]
~ O CERTIFICATEOF EXEMPTION FROM WORKERS' 8.00 FLOOD ZONE A.L.U.0
CL .
LL COMPENSATION INSURANCE PLG.CONTE. LIC.NO.
t] PLC.
D Z fThis section need not be completed if thepermit is for one TOT Y[:I
N[ Y [3 No
hundred dollars($100)or less.)
U'O I certify that in the performance of the work for which this per. CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,1 shall not employ any person in any manner so as to
O become subject to the Workers'Compensation Laws of California.
Imne-W NOT .Applicant SHANDLING
O,MECH. 4.00 BUILDING Al eo fv-
} y- NOTICE TO APPLICANT: If,after making this Certificate of Ex- '
? emption,you should become subject to[lie Workers'Compensation 4.00 PLAN CHECK
Provisions of the Labor Cade, you must forthwith comply with FEE
such provisions or this permit shall be deemed revoked IT(TO 10=QF.M.) 3.00
CONSTRUCTION LENDING AGENCY IT(OVER IQOOOC.RM.) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec.' MICROFILM
'
3097,CN.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name- "
Lender's Address H EATING UNIT(OVER 100,000 B.T.0-)7.50 ELECTRIC
I certify that 1 have read this appiwalion and stat,that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING' --7ordinances and state laws relating to building construction, and BOILER-COMP(3'H.P.or 100,000 B.T.U.) 4.00
hereby authorize above-Mentioned
tarries of This city to enter upon the BOI LER-COMP(Over 100,000 BTU)SEE FEE SCH.
abovmentionea proopertyerty for inspection purposes. - MECHANICALI,
(We)'agree to save, indemnify and keep harmless the City.of MISC.- REFER TO ORD. - ,h
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX 1
may in any way accrue against said City,in consequence of the .PERMIT ISSUANCE '3.00
gra ng of this pelmi MECH.CONT. LIC.NO. MECH: I
TOTAL TOTAL L !
t nature o Applicant ontrac[or - at r -' j
OFFICECOPY t