1293 (2) r
a— .
' CITY OF CUPEP.TINO ILISPECTIOLi RECORD (Office Copy)
1293
10700 N. neAnza Blvd.
PERMIT NO. SANITARY DIST. 110. LOT NO. ADDRESS
Remodel Four Phase 9U, -3 255-0900 Ext: 2037
PROJECT OWNER JOB SITE PHONE NO.
Date "' " ELECTRICAL
Building 11-2 -81 Date Insp.
Electrical 11-23-81 Power Pole
Plumbing Underground
IlechanicalP.ou h Wiring
Temp. Gas/Elect. a s
Solar Ceiling
Fire Sprinkler Fixtures Int/Ext
Sipn Motors
Grounding
Misc. Temp. Power
Other
FINAL INSPECTIONS Not Approved
Date Insp.
Elle
e PLU11B ING
Electric Date Insp.
Plumbing Backflow
Mechanical Underground
Solar Underfloor
• Pool Partial Rough
Grading Rough Complete
Planning Solar Rough
Fire Dent. Water & Insulation
Health Dept. *-Iain Drain
Building R/of/S Drain
Other Gas
Other
STRUCTURAL Not Approved �.
Date Insp.
Pad Certification MECHANICAL
Foundation Date Insp.
Pre-Gunite Underfloor S.M.
Slab-Membrane Ducts & Insulation
Bond Beam Fire Dampers
Underfloor Girders Fireplace
Floor Steel Grease Duct & Hood
T.iedowns One Hour Shaft
Diaphrams Condensate Drain i
Seismic Bracing Equipment Anchorage
Walls-Panels Flues & Comb. Air
Frames 1->i 0/ Other
Latham Not Approved
Wallboards Int Ext.
Firewalls
• Other
Not Approved
BUILDING +,
ELECTRICAL
•
PLUMBING
MECHANICAL
MISCELLANEOUS
APPLICANT TO-FILL IN-INFORMATION WITHIN RED LINES -_USE BALL POINT PEN Y
PERMIT NUMBER
A
BUILDING PROJECT IDENTIFICATION ' APPLICATION & PERMIT
BUILDING yJ
ADDRESS 1� J J
/oQ ;D" 204-Y•�w BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
I
GwNER'S - PLAN CHECK VALIDATION
S
"AME QTY. ELECTRIC PERMIT FEE.
I. ZS -0.�o0
ONE
CONraacroRs OUTLETS'-SWITCHES;RECEP '.5.00/1.00 ChB`
NAME
IC.NO. LIGHTING FIXTURES 5.00/1.00 (J71
AD - APPLIANCES-RESIDENTIAL 4.00
CONTRACTOR
DRRAcTRAC roR's_
DRESS
PHONE ` PANELS. 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6:00 PLAN CHECK FEE P.C.NO.
OR
' ENGINEER ,
ilc.NO. SIGNS TRANS. 3.00 '
AARC OORIESS
'OR ENG. SPECIAL CIRCUIT � Q •5.6D 1 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. nIh5.00
APPUCHNTSADRESS MOTORS - ecl V,40AWICH. -
SERVICE CHANGE ^^
wo O LICENSED CONTRACTORS DECLARATION
a u U I hereby affirm that 1 am licensed under provisions of Chapter 9 -'ISSUANCE DATE
G y' (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLO. M H-
H w i Professions Code,and my license is in full force and effect El
9?
o w - License Co.-Lic.Number
O F'ca Dale - Contractor .
¢ x s
dBUILDING PERMIT
¢ a, ¢ ¢ r OWNER-BUILDER DECLARATION C - - INFORMATION
w ° REFER TO ORD
F
3 u6.w I hereby afOrm that I am exempt from the Contractor's License MISC.- VALUATION
r a-0 ¢ Law forthe following reason. 7031.5,Business and Professions PERMIT ISSUANCE 6.00-
Code:Any city or county which requires permit to construct,alter,
le a ¢ 2' improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELECa. . J-/�
DLL requires the applicant for Such permit to file a signed statement that TOTAL 3Z e PERMIT TO
w $ he is licensed pursuant to the provisions of the Contractor's License ,
HZ >
Law(Chapter 9(commemciagwith Section 7000)of Division 3 ofthe
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE '
¢ O STORIES TYPE CONSTR.
¢ H o the basis for the alleged exemption.Any violation of Section
nam by any applicant fora permit subjects the applicant tell civil penally malty
'ALTER-DRAIN& VENT-WATER (EA.)4.00 - +
of not more than five hundred dollars(8500).):. '
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 ace.GROUP RES.uNrrs
their sole compensation,'will do the work,and the.stmcture is not
intended or offered for sole (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO,FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS a EA.SYSTEM-1 INC.4 OUTLETS 4.00 t
or improvement is sold within one year of completion, . .) 1.00 BUILDING USE
v RES IND ' CON PB Other
the owner- GAS-EASYSTEM-OVER 4(EA -
pro "no
builder will have the burden of proving that he did t build or im-
move for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
131,as owner of the property,am 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:The Contractor's License Law does not apply' -
to an owner of property who builds m improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 _
contracts for such projects with a c(.ntradons)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/6.00 - TRACT No.- PARCEL N0.
- -
\ ❑ I am exemptumder Sec.' ,B.&P .for fid WATER HEATER W/VENT 4.00
n '
reaso
Date D oC
OwWATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION .. WATER TREATING EQUIP. - 4.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.). '
Policy No. Company - --
� 0 CiCertiOedcopy is hereby furnished. - FIRE SPRINK -ENERGY T-24
Z Z ❑ Certified.'copy is Filed with the city hhspeclion division. -
O Applicant MISC.- REFER TO ORD. Y ❑ IN Y ❑ N❑
rutPERMIT ISSUANCE 6.00 FLOOD ZONE A.L.UG.
LU -
CERTIFICATE EXEMPTION FROM WORKERS'
lJJ > COMPENSATION INSURANCE PLG.CONTR, LIC.NO. PLG. -
IL tio
O (This seen Reed not be completed If file permit is for one TOTAL Y[:] N❑ Y ❑ N❑
� Z hundred dollars(S 100)or le"O
U Or I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
U hecolne subject to the Workers'Compunsution Laws of California. _
O n Date Applicant ALTER OR ADD TO MECH. 4,00 BUILDING
>_ m NOTICE TO APPLICANT: If,after making this Certificate of Ex- -
r Z emption,you should become subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK / p
provisions of the Labor Code, you must forthwith Comply with - ' FEE L (Ol
U such provisions or this permit shall he deemed revoked AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT.(OVER 10MC.F.M.) 5.00 1 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,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
'Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.P.50 ELECTRIC 3a
Lender's Address
1 edify that l 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
s
ordinances and state lawrelating to building construction, and
, BOILER-COMPI3 H.P.or 100,000 B.T.U.1'4.00
hereby authorize,representatives of this city to enter upon the BOILER-COMP.IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection put
posep h
(We) agree to save, indemnify and keearmless the City of MISC.- REFER TO ORD.
Cupertino agolre[ liabilities,judgments, casts and expenses which CONST.TAX
may in any way'accrue against said City in consequence of the PERMIT ISSUANCE 3.00 -
fSi, ,rCf'AFpIicaru/C
of t ' ern I. MECH.CONT. LIG NO. MECH.
C 043( . TOTAL TOTAL
onUactor Date
OFFICE COPY
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