7110 (2) CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
PhRMI] NO. ALWESS LOT NO,
UUwNbR
PERMIT ISSUED DATE ELECTRICAL DATE INSP.'
F _�.
tyl
cal
Plumbing Power Pole
mechanical r im
Re as ec main
Solar
a
Fire Sprinkler Ceiling
Sign ixtures Int/Ext
otors
Misc. Groundin
e ower
Other
FINAL INSPECTIONS DATE INSP. Not Approved
Gas
ectric
Plumbing PLUMBING DATE INSP.
mechanical
'Solar Backflow
•oo Underground
gra in oor
ann�n PartialRough
ire t. Rough Conplete
Health a t. Solar W2gh
u� ater ' ns anon
Other in . ain
o a3.n
Other
BUILDING DATE INSP, Not Approved
Pad Certification
Foundation ELECTRICAL DATE INSP.
Pre-Gunite
Slab-Membrane Underfloor S.M.
Bond earn cts nsu ation
UndertlooT it rsirFgace ers
oor teel --
ie owns Grease Duct 4 Hood
Diaphrams — ane Hour Shaft
eismec racin on nsate Drain
s- ane s ui ent Anc gage
rame lues & Comb. r
at Other
eFr
+a oar nt xt. -_ _ of r ve
irewa s
bt er _
Not Approved
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
°DILmNG10870 nroRT 645QuHR APPLICATION U PERMIT 7110
aoOREss
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME _ o OTY. ELECTRIC PERMIT FEE
PHONE O
CONT
CORS
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
S f sec.NO. LIG HT In FIXTURES 5.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS S.00 DATE OF APPLICATION
ARCHITECTSIGN$ B DD PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIc,No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS YA
ZIP EMP.METER OR POLE INS. 15.00
A...IGrvr's MOTORS SEE FEE SCH. �j, ///���aooREss f
S /�,$ /Lj/30YC SERVICE CHANGE 10.00 000
One. LICENSED CONTRACTORS DECLARATION
v u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
wa A (commencing with Section 7000)of Division 3 of the Business and LD ELECT. PLG. MECH.
F m z Professions Code,and my license is in full farce and effect. ❑ O ❑
z o In- License Class Lic.Number
O z r on O Date Contractor
s ¢w a OWNER-BUILDER DECLARATION -.BUILDING PERMIT
o A o MISC.- REFER TO ORD -'INFORMATION
w3 u H I hereby affirm that I am exempt from the Contractor's License VALUATION E/FT.
F.. 0 j Law far the following reason.(Sec.707 L5,Business and Professions PERMIT ISSUANCE 6.00
4mv, I rode:Any city orcounty which requiresa permit to construct,alter, ELEC.CONTE. LIC.NO. /
R Q O improve,demolish,or repair any structure.prior to its issuance.also ELEC.
-CLL requires the applicant for such permit to file n signed statement Ota[ TOTAL PERMIT TO
n w m he is licensed pursuant to the provisions of the Contractors License
Fri Law(Chapter 9(commencing with Section 7000)nf Division 3 al'the
-a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
C
file basis for the alleged exemption.Any violation of Section 7031.5 STORMS TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not mom than five hundred dollars(S500).):
1Q I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
Ib"n sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. '4.00
Code The Contractor's License Law does not apply to an owner of
I roperty who builds or improved thereon,and who docs such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employes,provided that such imlrrove-
profits himselRnnotlntended Or offered forown
sale.If,dehowever.uhebudding GAS-EA.SYSTEM-1INC.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 Ih,buNen al'proving that he did not build or im- ES IND CON PD Other
Prove for purpose of rule.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ D
❑ 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 55ESBORB PARCEL NO.
and Professions Code:'I'lie 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
can tracts for such projects with a contmclons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200f1/8.00 TRACT NO. PARCEL NO.
❑ I ons exempt atsder Sec. ,B.&P.C.for thus WATER HEATER W/VENT 4.00
rcnson
Owner Date WATER SYSTEM 4.00 ACG GATE ACC.FILE NO.
WORK E RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate ofemisent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance or a certified
copy thercofl Sce.3800,Lab.C.).
Policy Nn. Cen)pany
O ❑ Certified copy is herehy furnished. FIRE SPRINK ENERGY T 24
z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. Y ❑ NEI Y ❑ N[:]
Applicant
F � PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C.
LU >
CERTIFICATE OI°EXEMPTION FROM WORKERS'
i W � COMPIiNSA'I'ION INSURANCE PLG.CONTE, UC.NO. PLG. YNvE] NC3
❑ (This section need not be completed it the permit is for one TOTAL
Z hundred dollars IS 100)or less.l - -e
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE: FEE,,SUMINARY (;
LL P not is issued,I shall not employ any person in any manner so as to
U lleemne subject to the Workers'Compensation Laws of California. BUILDING .�
m Date Applicant ALTER OR ADD TO MECH. 4.00
6
} v) NOTICE TO APPLICANT': If,after making this Certificate of Ex-
F Z_ eruption,you should become subject to the Worker,,'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 I0=CF.NL) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING LIN IT 10=C.EM.) 5.00 SEISMIC FEE
1 hereby affirin ilia( there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the perk rmance of the work for which this permit is issued(Sec. MICROFILM
3097,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
1 certify that I 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 manly BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and star, laws relating to building cmiumetion. and
hereby nttmai, representatives of this city to enter upon the 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 CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
gr:mtin;ofthi, )c nn it. r / MECH.CONT. LIG NO. MECH.
� S TOTAL TOTAL
Sig . sere of Applicant Comracto Uufe t
14 OFFICE COPY
1