1374 (2) CITY OF CUPEP,TI.IO II:SPECTIOi? RECOP.D (Office Copy)
XX
1374 20377 Clay St.
PFR. IIT N0. SA\ITARY DIST. NO. LOT NO. ADDRESS
Plmb.i Keller 297-8107
PROJECT OLTNER JOB SITE PHONF NO.
Date ELECTRICAL
Building Date Insp .
Electrical Power Pole
Plumbin_ 2-22-82 Underground
ttechanical Rough Giiring
Tamp. Gas/Elect. ['a11s
Solar Ceiling
Fire Snrinkler Fi:ctures Int/E:;t
Sion Motors
Grounding
:disc. Temp . Power
Other
FINAL INSPECTIONS Not Approved
Date Insp.
Gas
Electric
PLIPIBIVG
Plumbing Backflow Date Insp .
?techanical Underground
Solar Uncle-floor
P001 Partial Rough
gradin
�~ lanninc Sough Complete
' Solar Sough
Fire Dent. Water & insulation
Health DeDt. Main Drain
Building R/of/S Drain
Other Gas
Other
STRUCTURAL Not ADDroved
Date Insp.
Pad Certification `IECHANTICdL
Foundation.
Date Insp.
Pre-Gunite Underfloor S.M.
Slab-?fembrane Ducts & Insulation
Bond Beam Fire Dampers
Underfloor Girders Fireplace
Floor Steel Grease Duct & Hood
Tiedowns —
One Hour Shaft
Diaphrams Condensate Drain
Seismic Bracing Equipment Anchorage
i.?ails-Panels Flues & Comb . Air
Frame Other
Lath
Not Approved
[lallboards Int/Ext .
Firewalls
Other
0 Not ADnroved
BUILDING
ELECTRICAL
PLUMBING
ElE CIT-hN I CAL
HISCELLANEOtiS
APPLICANT TO FILL IN INFORMATION WITHIN'RED LINES - USE BALL POINT PEN ONLY "
. +
BUILD[NG PROJECT I DENTI FICATION PE MIT R .
a-11mNOAPPLICATION & PERMIT - 1' "�_�, A
4
a00RE55 `7
� ` BUILDING=ELECTRICAL_PLUMBING—MECHANICAL
O NEE'
PLAN CHECK VALIDATION
I' nme QTY. ELECTRIC PERMIT FEE
0
CONTE O
NAME 'j OUTLETS-SWITCHES-RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00 -
CONTRACTOR'S
ADDRESS _ APPLIANCES-RESIDENTIAL 4.00
..P RON K, PANELS' 5.00
aRCHI CT4 M41' DATE OF APPLICATION
OR - - SIGNS - - 6,00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00'
ADDRESS END. SPECIAL CIRCUIT, 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00 h
APPLICANTS TE MOTORS SE SCH. P
,SERVICE CH - 10.00
00 LICENSED CONTRACTORS DECLARATION
rtu I hereby affirm that I`am licensed under provisions of Chapter 9, R (((
H 2 1St ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and _ -
.
BLDGELECT. PLG. MECH.
H G z Professions C �e, y license is in full fo '•gyld ,. ❑ ❑
Z, z w W License Clas 'Luc.Numbe ❑
r —
� r Date Contractor (• - - .
a m a OWNER- „ BUILDING PERMIT
_ m w BUILDER DECLARATION i
° a - MISC.— REFER TO ORD INFORMATION
Is ; u w I hereby affirm that I am exempt from the Contractor's License
r u O ¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00 VALUATION $/FT.
m � Code:Any city or county which requirosa permit mconslrucLalicq
EE 2 Q 0 improve,demolish,Or repair any structure,prior to its issuance,also ELEC_CONTR. L C.NO. ELEC.
u
A. requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m he is licensed pursuant to the provisions of the Contractor's License
HZQ Law(Chapter 9(commencing with Section 7000)of Dlvision3 oftlte v�- ��. .
4 O Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE /04
H p the basis for the alleged exemption.Any violation of5ection 7031.5 STOHIES -TYPECONSTR.
by any applicant for a permit subjects the applicant too civilpenalty ALTER-DRAIN -WATER (EA.14.00
of not more than five hundred dollars(S500).):
D I,as owner with the property,or my employees wwages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will the work,and the structure a is not
intended or offered for Sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CONE. 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 SD.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve. -
40,
mentsarenotintendedoroffered for sale.It,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 4,00
or improvement is sold within one year or completion,the owner. GAS EASYSTEM-OVER 4 IEA.) 1,00 BUILDING USE
builder will have the burden of proving that he did not build or im- - .
prove for purpose of the
RES.
IND CON PB Omer
❑ ❑ El 1:1
licensed
owner of the property,um exclusively contracting with
licensedd contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
town owner of property whhbuildso
o builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 7.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL No. -
❑ I am exempt under See, ,BARC.for thus WATER HEATER W/VENT 4.00 '
reason
Date Owner - WATER SYSTEM ' 4.00 ACC.OATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have a certificate of consent to self-insure,
Orpayce)rttiificcaatte of Worrkkers)Compensation Insurance,ora,ce�rtifi/4•d ZONING ENG.SITE NO.
PoGdtYmNVCbrrypeo.CJ. 1(�Y TJ • -
0 ❑ Cer[illed Copy is helnhy famished. FIRE SPRINK ENERGVT 24.-
0 Z �''Certified p is filed,with ilia city Inspection division.
H O ApTcant -/ MISC.- REFER TO ORD. y ❑ N❑ v ❑ rv❑
Cr W _ CERTIFICATEOF EXEMPTION FROM WORKERS'' PERMIT ISSUANCE 6.00 — FLOOD ZONE A.LUC.
LU > COMPENSATIONINSURANCE PLG.CONTR. LIC.NO. PLG.
M O (This section need not be completed if the permit is for ones TOTAL , v❑ N❑ V❑ N[3
IQ
hundred dollars($.100)or less.) /�
00 I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner so as to
Q W become subject to the Workers'Compensation Laws of California.
d Date ApplicantALTER OR ADD TO MECH. q,00 BUILDING
} N NOTICE TO APPLICANT'. If,after making this CeUi(iErF of lix
Fz emption,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 provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10)OODC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 5.00 SEISMIC FEE
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,Cc.C.). - HEATING UNIT ITO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B._T.U.)7.50
Lender's Address - ELECTRIC
VI certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 -
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction,'and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon [he
BOILER-COMP,IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and,keep harmless the City of MISC.- REFER TO ORD. - -
Cupertino against liabilities,judgments, Costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
any way a came against said City in consequence of the
rand of pe it. ' MECH.CONT. LIC,NO. MECH.
TOTAL TOTAL
ignatureo Applicant Contractor
OFFICE COPY
r