0266 (2) CITY OF CUI'ERTINO INSPECTSOI! RECORD (Office Copy)
0266 10581 John Way
PERitIT PIO. SANITARY DIST. NO. LOT NO. ADDRESS
. Appliance John Norden 253-7971
PROJECT 01-INER JOB SITE PHONE NO.
PERMIT ISSUED Date ELECTRICAL
Building Date insp.
Electrical Power Pole
Plumbing Underground
Ilechanical _ 6-1-81 Routh Wiring
Temp. Gas/Elect. hails
Solar Ceiling
Fire Sprinkler Fixtures Int/Ext
Sign ll tors
Grounding
Hisc. Temp. Power
Other__
FINAL IIISPECTIONS Not Approved
Date Insp.
r'e_s PLUMBING
Electric Date Insp.
Plumbing Backfloio
'lechanical Underground
Solar Underfloor
Pool Partial Rough
Grading Rough Complete
• PYanni.ng Solar Rough
Fire Dept. Water & Insulation
Health Dept. Main Drain
Bui.ldin R/of/S Drain
Other Gas
Other
BUILDING Not Approved
Date Insp.
Pad Certification MECHANICAL
FoundationDate Insp. I
Pre-Gunite Underfloor S.M.
Slab-Membrane Ducts & Insulation
Bond Beam Fire Dampers
Underfloor Girders Fireplace
Floor Steel Grease Duct & flood
Tiedowns One Hour Shaft
Diaphrams Condensate Drain
Seismic Bracing Eilnipment Anchorage
halls-Panels Flues & Comb. Air
Frame Other
Lath Not Approved
11allboards Int/Ext.
Firewalls
Other
Not Approved
it
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI_ POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NumeER
BUILDING APPLICATION & PERMIT O �^
AD E55 V
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL _
OWNER'S "" PLAN CHECK VALIDATION
NAME �1OTY. ELECTRIC PERMIT FEE
o A) - PHON (5-3-7921 ,
CONTERACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
NAIVE 'm.NG S, 21LIGHTING FIXTURES 5.00/1.00 -
ADDRESS oRs .cul. _ APPLIANCES-RESIDENTIAL 4.00
/2 t'l r PHONE , O PANELS ` 5.00 DATE OF APPLICATION
ARCHITECT, SIGNS,. 6.00 PLAN CHECK FEE P.C.N0:
OR ,
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.DR ENG. SPECIAL CIRCUIT -5:00 PERMIT VALIDATION
ADDREss-
iIP. - EMP.,METER.OR POLE INS. 15.00 -
APPUCANT's -'
ADDRESS MOTORS SEE FEE SCH. _
- -
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION to
a'u 1 hereby affirm that I am licensed under rovisionsof Clia ler9 YY_/
¢- Y P P ISSUANCE
w (commencing with Section 70001 of Division 3 of the Business and -
¢ RLDG. ELECT. PLG. MECH.
Hwi I'rofessiC Co' Co'C Liis in full for a e�_- ❑ ❑ ❑ I`h/-I/�I
'o i m G License C ass Lic.Number -
Date Contractor
i.¢ x f - BUILDING PERMIT
¢ ¢ w a- �' OWNIiRBUICDER DECLARATION - INFORMATION
dao• ° MISC.- REFER TO ORD
w H I hereby affirm that I am exempt,from the Contractor's License
y VALUATION $/FT.
a. 0 ¢ Law for the following mason,(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00.
f NNJ Cade:Any city or county which requires o permit 1.Construct,after,
M Q 4 0 improve,demolish,Dr repair any structure,prior to its issuance,also ELEC:CONTR.' , LIC.NO. ELEC. '
y iL O LL' requires the applicant for such permit to file a signed statement that /• TOTAL PERMIT TO
se S he is licensed pursuant to the provisions of the Contractors License '
H z r
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe PPG/,9Nt�.�
a Business and Professions'Code)or that he is exempt tberefonn and DTV. PLUMBING PERMIT FEE
T = the basis for the alleged exemption.Any violation of Section 7031.5 _ STORIES TYPE CONSTR.
.w by any applicant for a pefmil subjects the applicant to a civil penalty. ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
C] 1,as owner of the properly,or my employ.,willi wages as BACK FLOW PROTECT:DEVICE 2,00 OCC.GROUP RES.UNITS
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 does not apply to an owner of '
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 $O.FT.FLOOR AREA TOTAL ACREAGE
himself rethroughointended
own employees, le.IL hd that such improve-
mentsar1 his or employees,
ees,or lalf,however,the building GAS-EA.SYSTEM-1'INC.4OUTLETS 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 int- RES IND LOON PB Omer
,prove for 1.as ownerose
olf the p INDUSTRIAL WASTE INTER.- 20.00 C] � E
❑ L as owner of the property,he exclusively contracting with
licensed contractors to construct the project(See.7044,Business LAWN SPRINKLERS-.1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Use does nor.apply
to an owner of property who builds or improves thereon,and who LAWN SPR IN RS`OVER 5(EA.) 1,00 '
- contracts for such projects with a contractor(s)licensed pursuant to ' SEWER-SANT t/8.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec. .BAP.C.for this -
,"Son WgTER EAR W/BJUH 4,00 , -
s
Date Owner WATER SHVSTTEVENTMal 4.00 ACC.DATE ACC.FILE NO.
t
'I WORKERS'CONIPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I heathy affirm that I have a certificate of Consunl to sel Plnsom,. u1 - - ZONING
or a certificate of Workers'Compensation Insurance,or a certified - ENG.SITE NO.
copy thereof Sec. 900,Lab.C.I r'�
Policy N mpany.L.J=d, U
0 ❑ Cyy'ftifled copy is hereby firnished. - FIRE SPRINK ENERGY T-24
z Z 21('erlifi'd c y' i fit J w'h the city i,I pec Ion')v`ki n. MISC.- REFER TO ORD.
O Applicant -�LLFj- Y E] N� V❑ NE]
to PERMIT ISSUANCE 6.00
LU CE R'1'1 FJ CA'f TION PROM WORKERS' FLOOD ZONE AT.U.C.
W COMPI7NSA7'IONINSURANCF r PLG.CONTR. - LIC'.N0. PLG.
CL 0 (This section need not Abe Completed if the permit is for one TOTAL Y .NY ❑ NE]
Z) Z hundred dollm(S 100)or less.)'
0 O I certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
'� 0- Dare Applicant - ALTER OR ADD TO MECH. 4.00 BUILDING '
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Cade, you must forthwith comPlY with ;FEE
such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.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,Civ.C.L' HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Nome HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address - ELECTRIC -
I certify that I have read this application and slate that lire above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county - .PLUMBING
ordinances and slate laws relatingtobuilding Constriction, and BOILER-COMP H.P.or100,000B.T.U.) 4.00 7, '-
acreeof this
purposes
authorize representatives ec this city es enter upon 'the
above--mentioned property forinspection BOILER-COMP (Ovm 100,000 BTU)SEE FEE SCH. MECHANICAL •- '7 '��
' .
(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 s. CONST.TAX
mccruay in any way ."Re against said City in C. Sq.. a of the ) -
gra ingofthis per mit / MECH.CONT. LIC.NO. I MECH. ,
TOTAL TOTAL 7--
Signature of Appman Conhudnr Btu /"(L�y-T / -
OFFICE COPY