1356 (2) CITY OF CUPERT00 LNSPL'CTIOU RECORD (Office Copy) �v
i-45r, _ 22813 Long Down Rd.
PEPJIIT 110, SANITARY DISI, 110, LOT N0. ADDItI;SS
�J MPch Johnson
PROJECT OWNER JOB SITE PHONE NO.
PERMIT ISSUED Date ELECTRICAL
Buildinp, Date Insp.
Electrical Power Pole
Plumbing Underground —Mechanical 5-17-82 5-17-82 Rough Wiring _
Temp. Cas/Elect. Halls
Solar Ceiling
Fire Sprinkler Fixtures Int/Ext
Sign Motors
Grounding,
Misc. Temp. Power _
Other
FINAL. INSPECTIONS Not Approved
Date Insp.
r,e.s
PLUMBING
Electric
Date Insp.
Plumbing
Backflow
Mechanical Underground
Solar Underfloor
Pool Partial Rou h
Grading Rough Complete
�:11.1nninp Solar Rough
Fira Dept. Water & Insulation _
Health Dept. ".lain Drain
DUildin R/of/S Drain _
Other Gas
Other
BUILDING Not A roved
Date Insp.
Pad Certification 11ECIIANICAL
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 (tour Shaft
Diaphrams Condensate Drain
Seismic Bracing EquipmentAnchorage
Flans-Panels Flues & Comb. Air
Frame Other
Lnth Not Approved
Uallboards Int/Ext.
Firewalls
Other
Not Approved
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALI- POINT PEN ONLY
-r BUILDING PROJECT IDENTIFICATION - PERMITN
S ,CUING 0 APPLICATION & PERMIT . [;
AO v ll
BUILDING—ELECTRICAL—PLUMBING —MECHANICAL
OWNER'S PLAN CHECK VALIDATION
"A Y. ELECTRIC PERMIT FEE '
1 CONTRACTOR'S '
NAME - UTLETS-SWITCHES-RECEP 5.00/1.00
06 LIC.ry 0'IK 7 LIGHTING FIXTURES 5.00/1.00
CONTRACTOR
ADDRESS PPLIANCES-RESIDENTIAL 4.00
Aoo
/�-�
/x 2-Z Z� / PHONE Z/7 PANELS - 5.00 DATE OF APPLICATION '
ARCHITECT - PLAN CHECK FEE P.C.NO.
OR
SIGNS. - .B.00
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ARCH,OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
. .s SS
ZIP EMP.METER OR POLE INS. 15.00 -
Ars
ADORORESS MOTORS -SEE FEE SCH.
SERVICE CHANGE 10.00 .r
O¢z
Foo LICENSED CONTRACTORS DECLARATION - /, a L
¢U v I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DA E
,,aa z w (commencing with Section 7000)of Division'3 of the Business and
Q y 8 BLOC. ELECT. PLG. MECH.
o z Professions Cod nd icense is in full fore and f _
o02 a License ss Lic.Number P,F
,a Date Conlmctor 1,1
a m E BUILDING PERMIT
¢ ¢ ¢ OWNIi R-BUILDER DECLARATION -
o i u INFORMATION
E:
0 LL y 1 hereby affirm that 1 am exempt from the Contractor's License MISC.— _ REFER TO ORD
F u o J Law for the following reason.(Sec,7031.5,Businessund Professions pERMIT ISSUANCE 6.00 VALUATION S/FT.
Code:Any city orcoumy which requires a permit to construcLalteq
LIC.N0.
¢ ea ¢ o improve,demolish,or repair any structure,prior its issuance,than ELEC.CONTR.
L
ELEC.
w—DLL requires the applicant for such permit to file a signed slJl¢meml that ' TOTAPERMIT TO t
$m he is licensed pursuant to the provisions of the Contractor's License
�i > Law(Chapter 9(commencing with Section 7000).fDivision 3 of the 3
Q Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE L:G 1
IC f m the basis for the alleged exemption.Any violation of Section 7031.5 -STORIES TYPE CONSTR.
n by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN& VENT-WATER IEA.) 4.00
of not more than live hundred dollars($5000: - p
❑ I,as owner of the property,or my employees with wages as ,BACK FLOW PROTECT.DEVICE 2,00 - OCC.GROUP RES.UNITS,
Sole compeasafian,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of -
property who builds or improves thereon,and who dues such work FIXTURES-PER TRAP 4.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
. menta are no,Intended or offered for sale.If,however,the building GAS-
EA.SYSTEM INC.40UTLETS-4,00
or Improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. - 20.00
❑ 1,as owner of the property,am exclusively contruttin ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply ,
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 7.00
- contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. - SEWER-SANITARY-STORM. EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.—,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4,00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPF:NSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure. ZONING ' ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a cerlificJ
Copy(her Sc 0 Lah.C.L
Policy No / ' 'omPanY 6�'L
Q ❑ �erlified Copy is hereby fufniahed. FIRE$PRINK ENERGY TZd '
Z Z Cenifie cop ,y" c wj t city i p I' di t. MISC.- - REFER TO ORD.
O APPlicamt ❑ IN 'Y ❑ N❑
~ va PERMIT ISSUANCE 6.00 ILFY100D ZDNE A.L.u.c.
CERTIFICATE OF EXEMPTION FROM WORKERS' -
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLGCL 0 (This section need not be completed if the permit is for one TOTAL ❑ N❑ Y ❑ IN E]
0 Z hundred dollars IS 1001 or less.)
U O I certify that in the performance of the work for which this per. CITY. MECHANICAL PERMIT FEE FEE SUMMARY
'LL F• mit is issued,I shall not employ any person in any mannerso as to
U become subject to the Workers'Compensation Laws of California.
0 y Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} m NOTICE TO APPLICANT: If,after staking this Certificate of Ex- „
I.. ? emption,you should become subject to the Workers'Compensation APPLIANCE ' 4.00 PLAN CHECK'
provisions of the Labor Code, you mustforthwith comply with FEE
f t such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10DODC-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.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000B.T.U.P.50 ELECTRIC -
Leader's Address
I certify 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
♦ ordinances and state laws relating to building construction.and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
rfereby authorize representatives Of this city to enter upon the BOILER-COMP_b0aer 100,000STU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection Purposes.
.(We) agree to Save, indemnify and keep harmless the City ofMISC.-- - REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which 'PERMIT ISSUANCE - 3.00 CONST.TAX
may in any way accrue againsl'said City in consequence of the
grting of this perm MECH.CONT. - LIC.NO. MECH.
n TOTAL _ TOTAL
Signilraulre of nt Contractor I Date /'/
, , - OFFICE COPY