5497 (2) 1
i CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
1575 aeey AJAy
PhFJvUT NO.
PROJECT
UWNhK
PERMIT ISSUED DATE ELECTRICAL DATE INSP.
F1n 7. �4L
rica �,
Pluffbing �, Power Pole
Ffe iiaamca
Imp as ec �ojun wiring
Solar a s
FireSprinkler ei ing
i r
ixtures Int/Ext
Motors
Misc. Ground
We, ower
er
FINAL INSPECTIONS DATE INSP. of rove
Gas
Electric
Plumbing PLUMBING DATE INSP.
tical
�,o ar Backflow
00 r un
Grading r Poor
Planning arti oug
Fire t. Aug amplete
Health t. Solar ru i
ui in ater ' Insulation
er in . ain
o rain
Gas
D-her
BUILDING DATE INSP. Not Approved —
Pad Certification
otm ation ELECTRICAL
re- ate DATE INSP.
Slab-Ntmbrane Underfloor S.M.
Bond Beam M-c-t—s-71nsulation
Underfloor it rs Fire Darpeys
Floor SteelFireplace
ie owns Grease Duct & Hood
Diaphrams a our Shaft
eismecracin Condensate Drain
Wa-Tls- ane s ui ent Anchorage
rameues r
Other
�a oar nt xt. of rove
Firewalls
other
Net Approved
A 1'LICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
' BUILDING PROJECT IDENTIFICATION gppLICATION & PERMIT PERMIT NUMBER
So LDING
ADDRESS
S S' BUILDING—ELECTRICAL—PLUMBING—MECHANICAL 5497
NAMERS x PLAN CHECK VALIDATION
J�ONs//� /� y/� t]TV. ELECTRIC PERMIT FEE
fL 4O "" PHONE y1y jl
NAMERAcaona UTLETS-SWITCHES-RECEP 5.00/1.00
LIC.NO. LIGHTING FIXTURES 5.00/1.00
ccrOBa
CONTRADDRESS - PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
OflRCHITECr SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
L.C.No. SIGNS TRANS. 3.00
ADDRESS ENa. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
zIPITEMP.METER OR POLE INS. 15.00
Ars
ADDRESS MOTORS . SEE FEE SCH. bol Qv/y
ADDRESS
SERVICE CHANGE 10.00 q y
oD LICENSED CONTRACTORS DECLARATION // //U
a i w _ I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
r (commencing with Section 7000)of Division 3 of the Business and
r-<y BLDG. ELECT. PLG. MECH.
r w Z Professions Cole,and my license is in full force and effect
o i m C License Class Lic.Nwnher
Uale Conlmctor
I-
o n D OWNER-BUILDER DECLARATION BU PERM T
W ; a m I hereby affirm that 1 am exempt from the Contractor's License MISC.— REFER
H y m 4 Law for the following mason.(Sec.7031.5.Businessind Professions PERMIT ISSUANCE 6.00 dd AAAA;DATION S/FT.
Code_Any city or county which reyuiresa permit to cons)rum,aller, 94 I' 1 7 1p
QQ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. fJ-o J
DLL requires the applicant for such permit to file a signed statement that TOTAL / N
' w$ he is licensed PUTSDant to the provisions of lire Contractor's License CiPERMIT TO
i ty O`
FZLaws�p''pe►tIo
Q Business and Professions Code)or(hat he isexempt therefrom and OTY. PLUMBING PERMIT FEE ? s{ 0
a I_$ 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 toacivil penalty ALTER-DRAIN -WATER IEA.14.00
of not more than five hundred dollars 155000.1:
❑ 1,as owner of the property,or my employees with 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 Convector'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 _ Sp FT,FLOOR AREA TOTALACREAGE
himself or through his own employers,provided that such improve-
meets are not intended or offered for sale If,however,the building GAS-EA.SVSTEM-111NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4(EA.) 1,00
builder will have tire - . - . BUILDING USEe burden of proving that he did not build or im- RES INN CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 2000
E) 1,as owner of the property,an 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:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS- .A.1 1.00
contracts for such projects with a contrclor(s)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM 20Oft/6.00 TRACT NO. PARCEL NO.
0 15m cxem tender Se . ,BAP.C.for thisWATER HEATER / N 4.00
reason W 1,, 1964
Owner Date _ r WATER SYSTEM 4.00 ACC.PATE ACF FILE NO.
WORK I:RS'COMPE SA'fION DECLARATION WATER TREATI4.00
1 hereby affirm That I have a certificate of consent to scl&insur¢, 20NING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or u certified
copy[horeof(Sce.3900,Lab.C.).
Plicy No.' Company
O ❑ 1
FIRE SPRINK ENERGY TQ4
Z Z ❑ Certified copy is Bled with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y N[] Y ❑ N�
~ vaPERMIT ISSUANCE 6.00
� —
CERTIFICATE OF E%EMPI'ION FROM WORKERS' PERMIT ZONE A.L.u.c.
W 1 COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. &L,CL O (This section need not be completed if the permit is for one TOTAL Q ` Y❑ NC] Y 0 NEl
� Z hundred dollars($100)or less.) -
U O 1 certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mil is issued,I shall not employ any person in any manner so as to
O,w become subject to the Workers Compensation Laws of California.
Date
.Applicant Applicant BUILDING (,�[�fa
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 4.00 41
F. z emption,you should become subject In the Worker's Compensation APPLIANCE 4.00 'PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10AEL 3.00
CONSTRUCTIONLENDING AGENCY AIRHANDLINGUNITIO 0 SEISMIC•FEE f�
I hereby affirm That there is a construction lending agency for EXHAUST HOOD(WI UC 0 •J
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.i HEATING UNIT(TO
Lender's Name HEATING UNIT IDVERI ,0 1s,; OT!
Lender's Address ELECTRIC _
I certify that l have read thisapplication and stale that the above VENTILATION FAN ISINGLE) 3.00 0Vinformation is Correct.I agree to comply with all city and county BAILER-COMP13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING �Q
Ordinances and state laws relating to building construction,and
hereby authorize representatives of this city to enter upon the BOILER-COMP IOver lUUp00 BTUI SEE FEE SCH. MECHANICAL �O
above-mentioned Property for inspection purposes.
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liahilities,judgments,costs and expenses which �-Cx
rCONST.TAX
may in y way a me against said City in consequence of the PERMIT ISSUANCE 3.00
of this MECH.CONT. LIC.NO. MECH.
j TOTAL
TOTAL
Signature of Applic tIConttactor Uat
`OFFICE COPY