4996 (2) CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
PERMIT NO. O V
DRESSOWNER
LINO 6,—
�-rr� AJIA
PERMIT ISSUED DATE ELECTRICAL DATE INSP.
Building
hlectrica
Plumbing Power Pole
anica oer un
u as ec rin
r a . . .
Waiis
Fire Sprinkler Ceiling
bign Pixtures Int/Ext
Motors
Misc. Grounding
Te dower
Other
FINAL INSPECTIONS DATE INSP, Not .Approved
Gas
Electric
Wum in PLUMBING DATE INSP.
anica
olar Backflow
Wool r roun
Grading er oor
Planning Partial ou
Fire Dept. RouLh Complete
ea t e t, 113olar ou
$i73in atelation
Other Main 'Drain
o rain
as
t er
BUILDING DATE INSP, Not Approved
Pad Certification
oun ation ELECTRICAL DATE INSP.
re- unite
Slab-Membrane Underfloor S.M.
Bond eam Ducts & Insulation
Underfloor Girders Fire Dampers
Floor Steel ire ace
ie owns Urease Duct 6 Hood
iap rams One ' our 'Shaft
eiismec Bracing Condensate Drain
Walls- a els E5uipment Anchorage --
Frame 141ues 4 Comb. Air
at Ot er
MWaliboar n xt. _ 3– It
of rove
Firewalls
Other
Not Approved
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI_ POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 4996
�\ ADDRESS
!�i/E BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S:fes PLAN CHECK VALIDATION
NAME ++, `�GM1-1613ory/sU QTY. ELECTRIC PERMIT FEE
/rrl- �t�l/a✓Cer PHONE�ff
corvrRAcaoRs j/?LL .Qt1TlbLS �37 OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME i
"-^ 0% LIGHTING FIXTURES 5.00/1.00
corvrRALTOR's PPLIANCES-RESIDENTIAL 4.00
Ao Ess (� �1 (� -�,f
//t ZONE 9//f 7T� Wo PANELS 5.00 DATE OF APPLICATION
AR lj yUZ� SIGNS 6,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.NO, SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT S.OD PERMIT VALIDATION
ADDRESS
ZIP TEMP. METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
woo P
LICENSED CONTRACTORS DECLARATION
' u 1 hereby affirm that I am licensed imde.......men,of Chapter 9 ISSUANCE DATE
sea N (commencing with Section 7000)of Division 3 of the Business and ®L F7 ry PLG. MECH.
H o. Profe.aionsC ¢ d my lice cis in full force:u d effect D `t
z
0.0 Licenu Cla z ✓'+r+tl7-�-ic.Number ❑ ❑
'Dale Contractor
y ru,
ar
w a OWNFiR-BUILDGR DECLARATION �yr,,[p}{�yN,�G PERMIT
m o a MISC.- REFER TO ORD �f ��jY e"^MATION
w S LL H 1 hereby of lion that I am exempt front the Contractor's License VALUATION S/FT.
Fu Oj Law for turn following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00 e .. '
Code:Any city or county which requires a permit to construct.alter, PA
rc ¢ o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. /
O M requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w m he is licensed pursuant to the provisions of the Contractor's License Ii
a, z ve Law.(Chapter 9(commencing with Section 7000)of Division 3 of the y
a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT E IJ
¢ m the I,asis for 0m alleged excmptirin.Any violation of Section 7031.5 5T0(gfG$� TYPE CONSTR.
d ; _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.14,0 t 0
of not more than five hundred dollars(S500).1: PErtino
❑ I,a owner of tire Property,or my cmPluy¢eswith wagcsas BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is nm
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 docs such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
mm
esare notimmpdcd or.1fvo,d Iorsa1a.ILhowcvcr,the building GAS-EA.SVSTEM-1 4.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA) 100 BUILDING USE
builder will have the border of proving that he dirt not build..r int . . .
- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed emrtradors 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 dries not apply
rn an owner of property who builds or intprci theocon.and who LAWN SPRINKLERS OVER 5(EA,) 1.00
contracts for such projects with a commetorfs)licensed pursuant to
the Contractor's License Law. ISEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ [,1 exempt under Sec. .B.&PC.Ou Ibis WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORK ERS'CONIPENSAIION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to sel Ginom,. ZONING ENG,SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800.Lah.0
Policy No.- �&
wl
O ❑ Certified copy is hereby
fDlni)II¢J. FIRE SPRINK ENERGY T-$4
Z ❑ Cortif u, y Is 1•d Nth the city inspection division. MISC.- REFER TO ORD. y❑ N❑ Y ❑ N❑
Q Applicant
CC CERTIFICATE OI'EXEMI'DON PROM WORKERS. PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.U.
UJ > CONIPF-NSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d 0 1'I'his section need not be completed if the permit is for one TOTAL Y[:] N❑ v ❑ N❑
::) Z hundred Aollors($100)or I.,.l
U O I certify that in the performance of tire work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL P- mit is issued, I shall not employ any person in any manner so as to
O w become subject to the W'orkers'Cmnpensatian Laws of Calilirnia. BUILDING
d Date Applicant ALTER OR ADD TO MECH. 4.00
} m NO'Ikinof
'ICI: '1'O APPLICANT: If,after mag this Certificate Ex
m -
? eption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10OMC.F.M.) 3.00
CONSTRUCTION LIiNDING AGENCY AIR HANDLING UNIT(OVER 10=C. M.) 5.00 SEISMIC FEE s'�J
I hereby affirm that there is a Construed....lending agency for EXHAUST HOOD (WITH DUCT) .0
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Co.C.). HEATING UNIT(TO 100,000 e.T.U.) 4.00
Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.17.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
Information is street. I s rel to Comply with all city and countyand BOILER-COMP(3 H.P.or 100,000 B.T.U.1 4.00 PLUMBING
ordinances and state laws relating lir building const twat ion, and
hereby authorize representatives of this city to enter upon It.¢ BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned 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 PERMIT ISSUANCE 3.00 CONST.TAX
rimy in any way accrue against said City in consaquat cc of the
grant0lg o lh is perml MECH.CONT. LIC.NO. MECH.
�� � //o�B� OTAL TOTAL
Signature'of Applicant/Corrmctor mate e
OFFICE COPY.