0546 (2) CITY OF CUPEIITLNO INSPECTIOL' RECORD (Office Copy) p
Y v/ice(}
0546 1 _ 836 Kim St. _
PCPJIIT NO. SANITARY DIST. NO. LOT NO. ADDRESS
'• Reroof Thomas Atkins 252-7636
PROJECT OWNER JOB SITE PHONE NO.
PERMIT ISSUED Date ELECTRICAL
Building, _ � - — Date Insp.
Iaectrical Power Po_te
I'Lumhing Under ,round
Mechanical Rough Wiring
Tana. Cas/Elect. I1aI1.i
Solar Ceiling
Fire Sprinkler Fixtures Int/Ext
Sign Motors
Grounding
Mise. Temp. Power
Other
PINAI. I14SIlECTIONS Not Approved
Date Insp.
"s PLUMBING
Electric Date Insp.
plumbing Backflow
Mechanical Underground
Solar Underfloor
Pool Partial Rough
Grading Rough Complete
•
Planninr Solar Rough
Fire Dept. ldater & Insulation
Health Dept. Main Drain
Building R/of/S Drain _
Other Gas .
Other _
BUILDI14G Not Approved
Date Insp.
1'ad Certification MECHANICAL
Foundation Date Insp.
Pre-Gunite Underfloor S.N.
Slab-Membrane 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
Halls-Panels Flues & Comb. Air
Frame Other
Lath Not Approved
Wallboards Int/F.xt.
Firewalls
Other
`. Not Approved .
APPLICANT TO FILL IN'INFORMATION WITHIN_ RED LINES - USE B'ALC POINT PEN ONl
BU I LDING PROJECT I DENTIFICATI ON RMITNUMBER.
BUILDING APPLICATION & PERMIT 0
ADDRESS q I_ _
✓{ f%. 3 546
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
-�
OWNER'S PLAN CHECK- �,�_�� QTY. - ELECTRIC PERMIT FEE- vnuonnory
NAME /
I
Ovfxc S aNE
NAMERACTORs OUTLETS-SWITCHES-RECEP :5.00/1.00
LIC No. LIGHTING FIXTURES 5.00/1.00 '
CONTRACTOR'S APPLIANCES
4.00
ADDRESS
PHONE PANELS - 5.00 DATE OF APPLICATION
ARCHITECT - SIGNS d Q ° 6.00 'PLAN CHECK FEE P.C.NO.
OR
ENGINEER', '
LIC,NO, SIGNS TRANSfJ` - '3.00
ARCH.OR ENG.- ' ,. PERMIT VALIDATION
ADDRESS SPECIAL CIR T Q.' '5.00
ZIPT - EMP..METER R POLE INS. 15.00 /'1„
APPLICANT - '�. MOTORS - SEE FEE SCH. �2-
ADDRESS
SERVICE CHANGE 10.00
0
'02 LICENSED CONTRACTORS DECLARATION
M u u I hereby affirm that I am licensed mol provisions of Chapter 9 'ISSUANCE DATE
y 4 y (commencing with Seel ion 7000)of Division 3 of the BUsiness and - s BLDG. ELECT, PLG. MECH.
r o 2 Professions Code,and my license is in full force andeffecl. - ❑ ❑ ❑ '
Z O N License Class Cie.Number
2 z o Date - tr
Conactor
xs � •' BUILDING PERMIT
IS Be w a OWNFR-BUILDER DECLARATION - INFORMATION
woAe' MISC. REFER TO ORD
LL N I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT:
FLLo J Law for the following nason.lSec.703 L5,Business and ProfessionspERM1T ISSUANCE_ 6.00
0i Code:Any city or county which requiresa permit toconstrucU alter. IT
te Q a Improve,demolish,or repair any structure,prior to its Issuance,also ELEC.CONTR.'• - LIC.NO.
w
G ¢ requires the applicant for such permit to file a signed statement that - • TOTAL PERMIT TO
t' w $ he is licensed pursuant to the provisions of the Contractor's License p
rii Law(Chapter 9(commencing with Section 7000)of Division 3offoe
a Business and Professions Coder or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE 't
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTH.
p by any applicant for a permit subjects the applicant too Civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars($500).1:
❑ I,as owner of(lie property,or my employees with wages as BACK F LOW 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 SO.FT.FLOOR AREA TOTAL ACREAGE
himse• mems are not
or offered for
provided Wmsuch impnrve GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
menta are not intended or offered for sale.If,howevc such building
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 inr' RESIND CON PB Omer
prove for purpose of sale.). ' INDUSTRIAL WASTE INTER. 20.00 '�
❑ I,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: rhe Contractor'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 contractor(s)licensed pursuant to
the Contractor's License law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
X .❑ 1amyxe It�s•r Sec. B.&PC.forthis WATER HEATER W/VENT . 4.00
Mason
�r-
Duce Owner WATER SYSTEM , 4,00 ACC.DATE ACG FILE N0.
WORK CRS'COMPF NSAT1ON DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent m self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance;or a certified
copy thereof(Set.3800,Lab.C.l.
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is Bled with the city inspection division. REFER TO ORD.
MISC.-
Q ' Applicant � - Y � N� Y � N[:] -
~ CERTI PICF EXEMPTION FROM WORKERS' 'PERMIT ISSUANCE - 6.00
'FLOOD ZONE AL.U.0
W COMPNSTIONINSURANCE .
� PLG.cONTR. uC.NO. PLG.
0-Z (This sections need not be completed if the permit is for one _ NOTAL Y N❑. Y N�
hundred dollars($100)or less.) "-
U 0 1 certifythat in the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL f mitis issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California. p
� y Date Applicant ALTER OR ADD TO'MECH. 'q,00 BUILDING 30/�
} N NOTICE TO APPLICANT: If,after making this Certificate 0f-Ex- - -
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. - 'AIR HANDLING UNIT(TO 10)000C.F.M.) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000GEM.) 5.00 SEISMIC FEE es'�
1-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 fSee. MICROFILM
3097,CN.C.). H EATING UN IT (TO 140,000 B.T.U.) 4.00
Lender's Name'
Lender's Acidic HEATI NG UN IT(OVER 100,000 B.T.U,)7.50 ELECTRIC
ss
I certify that I have read this application and stale that the above. - VENTILATION.FAN (SINGLE) 3.00
information n correct. I agree to comply with all city and county - PLUMBING
ordinancesinformation
andsmtct. I aret ing octobuildingl city and wand BOILER•COMP(3H.P.or 100,000 B.T.U.) 4.00
hereby,authorize representatives of this city 10 &mer upon the BOILER-COMP'IOver 100,000 BTU)SE E FEE SCH. MECHANICAL
ubovennentioned 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 CONST.TAX
may in_joy way accrue against said City in consequence of the , PERMIT ISSUANCE 3.00
Spun
(this permit� �.�- / JJ MECH.CONT. . LIC.NO. MECH.
1� �,w {�-z1?. I TOTAL TOTAL 39 Do
Signature o�icant/Contractor Date '
OFFICE COPY _'""`r.� -