0263 (2) C.I'FY OF CL'PERT'LNO IUSPECTIOb RECORD (Office Copy)
0263 20075 Forest Ave.
P1:Pd1IT NO. SANITARY DIST. NO. LOT NO. ADDRESS
Plumbing Dlask
PROJECT OWNER JOB SITE PHONE NO.
PERMIT ISSUED Date ELECTRICAL
Bui]dtnr Date Insp.
El.ectrLcal Power Pole _
I'Lumhing - - Under ,round
Mechanical RouFF;h Wiring
Temp. Gas/Elect. 11alls
Solar Ceiling__
Fire S12rin.kler Fixtures Int/Ext
Sign ilotors
Grounding
Hisc. Temp. Power
Other
FINAL INSPECTIONS Not Approved
Date Insp.
(,2s _
PLUMBING
Electric Date Insp.
Plumbing Backflow
Mechanical Underground
Solar Underfloor
Pool Partial Rou ,h
Gradinp Rough Complete
• 11Yannin Solar Rough
Fire Det. Water & Insulation
Health Dept. Main Drain
Building R/of/S Drain
Other Gas
Other
BUILDING 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
Tiedowns One Hour Shaft
Di.aphrams Condensate Drain
Seismic Bracing Equipment Anchorage_
11alls-Panels Plugs & Comb. Air
Frame Other
Lath Not Approved
11allboards Int F.xt.
Firewalls
Other
Not Approved
AFPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 02639=5
D
= BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
PLAN CHECK VALIDATION
Me
vfloNE QTY. ELECTRIC PERMIT FEE
NOMaERAc.oRs UTLETS-SWITCHES-RECEP 5.00/1.00
Ic.N . LIGHTING FIXTURES 5.00/1.00
CONTE AOTOR's
ADDRESS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
�t HON 1 PANELS 5.00 DATE OF APPLICATION
-401
ORCHrt T SIGNS 6.00 PLAN CHECK FEE P.0.NO.
ENGINEER
LIC,NO, SIGNS TRANS. 3.00
ARCHOR ADDRESS ENG SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT'$
ADDRFS5 MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
0 0 o LICENSED CONTRACTORS DECLARATION N d
a U Lbs I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
h a c (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH.
H o i Porre.License C C Ih liters,is in full fuu
x o 0 - Liana Clas _ s,i Numbs
0 w - D Date Contractor
¢ m BUILDING PERMIT
¢ w a OW'NF,R-IIUILDF.R DECLARATION
K
;LL v, I hereby affirm that 1 em exempt from the Contactor i License
MISC.- REFER TO ORD INFORMATION
H m o g few for th<following reason,(Sec.703 1,5,Business and Professies ons PERMIT ISSUANCE B VALOATION 5/FT.
Code:Anycityorcounty which requira permit to construct.alter.
or ¢ improve,demolish,or repair any'stnature,prior to its issuanc0.also ELEC.CONTR. LIC.NO. ELEG
- D or requires the applicant for such permit to file a signed statement that TOTA.L PERMIT TO
w$m he is licensed pursuant to the provisions of the Contractors Licensez a Law(Chapter 9(cnmmenciag with Section 7000)of Division 3 of the
i o Business and Professions Code)or that he is exempt therefrmn and QTY. PLUMBING PERMIT FEE
w F 0 the basis for the alleged exemption.Any violation of Scerion 7031.5 STORIES TYPE CONSTR.
a3 _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more then five hundred dollars($500R.)
❑ I,as owner of the property,or my employ,%,with wages as BACK F LOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their Sale compensation,will do the work,and the structure is not
intended or offered for rule (Sec. 7044, Business .,,it Profcssimu 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 flocs such work F IXTUR ES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employers,Pe.If,ho that such improve-
mcntsarenotinrandedoroffereoyees,provided
ed that r.such
building 'GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is 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 iso- RES IND CON PB One,
prove for purpose of sale,). INDUSTRIAL W ASTE INTER. 20.00
❑ I,as owner of the property',am exclusively contracting with
licensed contractors to construct the project IScc. 7044,BusinessLAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Profession%Code:The Contactor's License Law does 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 Couloacturlsl licensed Pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I um exempt under Sec. ,B.&P.C.for Ills WATER HEATER W/VENT 4.0
reason
Date Owner WATER SY 4.00 ACC,DATE ACC.FILE NO.
WORKERS'COMPE-NSATION DECLARATION WATERi7RF.*WERTjN0 4.00
I hereby affirm that I have a certificate ufconsent to self-insure.
or�+ay cjeyrtiyfi{c�ate of Workers Compensation Insurance,or a ccrtificd ZONING ENG.SITE NO.
O q-.Cera9ed copy Is hereby furnished,
.6` FIRE SPRINK ENERGY T]4
z Z Cet ynifed dad with the city inspection division.
o_ ApplicanMISC. - _ ' REFER TO ORD. v N� v NN[:]~ PERMIT ISSUANCE
Du CIiRTIPICCOIIPE fAiI N INSPROMN'ORK8R5' 6,00 FLOOD ZONE A.L.l1c.
W � COMPIiNSA'I'ION INSURANCE PLG.CONTR. LIC.NO. PLG. /� T
CL Z (This section need not be completed if the permit is.for one TOTAL/0,00 y❑ No Y El N�
hundred dollars IS 100)or I.,)
U O 1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE
W F mit is issued, I strait not employ any Poison in any mmnncrso us to FEE SUMMARY
O w become Subject to the Workers Compensation Laws of Calitornia.'
d Date Applicant BUILDING
} rn NOT[CI! 'f0 APPLICANT: If,after making this Certificate of fix- ALTER OR ADD TO MECH. 4.00
F ? emption,you should bcoame subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith 'amply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1QOW 1CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that were is u construction leading agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cis'.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's AddreHEATI NG UNIT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
ss
I certify that I have read this application and state that the above V ENTI LATION FAN (SINGLE) 3.00
information is correct. I agree to comply'with all city and county PLUMBING
ordinances and state laws relating to building ciao ruction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authariee representatives of this city to enter upon the BOILER-COMP (Oven 100,000 BTUI SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgnwms, costs and expenses which CONST.TAX
may in any ay accrue against said City in consequence of the PERMIT ISSUANCE 3.00
n tin t I pmnut' MECH.CONT. LIG NO. MECH.
TOTAL TOTAL
nthincWFApplicant/Contractor Date VV JJJ
OFFICE COPY