7036 (2) CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
OWNER
PERMIT ISSUED DATE "ELECTRICAL DATE INSP.'
Electrical
Oin Power Pole
anus r�roun
e as ec Roughh-Rhin
Solar Walls
Fire Sprinkler ei in
bign J=res Int/Ext
otors
Misc. roue in
e ower
Other
FINAL INSPECTIONS DATE INSP. Not Approved
Gas
Electric
Plumbing PLUMBING DATE INSP.
anica
o ar i— Backflow
0o r un
Grading r oor
Planning Partial Rough
Fire t. u o ete
eat a t. oar ougn
i i ater ' Insulation
erin . ain
oDrain
Gas
Dther
BUILDING DATE INRP. Not rove
Pad Certification
oFim3ation ELECTRICAL DATE INSP.
re- unite
blab-Membrane Underfloor S.M.
on am cts nsu ation
mWndertloor iersire ers
Floor tee i�re�a_ce
ie owns Grease h ct 1;' Hood
is rams one Hour Shaft
eismec Bracing Condensate Drain
s- ane sui ment Anchorage
rame Flues 4 Comb. Air
Admathter
q"allboards Int/Ext. of rove
virewa s
other
Net Approved
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT-PEN ONLY
PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION BUILDING APPLICATION & PERMIT
1 NDnnEss
T ApzE2 24kbPA c�T. 7036
Z BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNEfl'$
NAME hA.f*, PLAN CHECK VALIDATION
. hl�Ke ' 1 L'p'l ZS 0,L�Q7Y. b a°'-.#w"^ ELECTRIC"PERMIT'�*: '`'"* aFFEEYw' 3� Fes-
1't �+l R PHONE (/
NOANTRACroRs OUTLETS-SWITCHES-RECEP 5.00/1.00
JQi-R-rte 57� LIGHTING FIXTURES 5.00/1.00
NC1W LIC.Na,3 � ,
CONTRACTOR'S cC-P76 yl$) PPLIANCES-RESIDENTIAL 4.00
ADDRESS (w� (�
1775OL� CA(W 4 PHONES`13 Q-fo PANELS S.00 ,` DATE OF APPLICATION
DRRCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER EN
LIC.NO, SIGNS TRANS. 3.00
ADDRESS ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS' - MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE ®ATO 10.00
• 0
' ' Foo LICENSED CONT'RACT'ORS DECLARATION '
a v I hereby affirm that 1 am licensed under provisionsuf Chapter 9 r1G�+ .y '� '
a 2 w ISSUANCE DATE
yaw (commencing with Section 7000)of Division 3 of the Business anA ..._ BLDG. ELECT. PLG. MECH.
H D z Professions Cod nd license is in full to rf• 1
Z
0 H{/I License Cl'cs_ Lie.Numbs _ p
r w r 7:1` Datc_2/ Contractor City of `�pertino ❑ ❑ ❑ ❑
".BU I L DING'PERMIT
Ic 0 w a OWNER-BUILDERexam t from RA'T'ION `°'"+`.INFORMATION
o^' "' MISC.— REFER TO ORD ''I+"� L_-
w ;U.0 w 1 hereby al firm that I am exempt from the Contractor' License VALUATION $/FT.,
LL-o j Law for the following reason.(Sec.7031.3,Businessand Professions
- g PERMIT ISSUANCE 6.00Code:Any mulish Cor ply whiny retlistructureasa p prior
t U conis estimate,also
C )
¢ 0 improve,demolish,Or repair any structure.prior 10 its issuance,alsU ELEC.CONTE. - LIC.NO. ELEC.
m u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w - o he Is licensed pursuant to the provisions'of the Contractor's License , A P Lino
H z s- Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe a ,(I:"as?' NOZ (1 1,11 -�
i o Business mad Professinex Code)or that he is excerpt therefrom and OTY;i PLUMBINGTERMIT a FEET{'
the basis for the alleged exemption.Any violation of Section 7031.5 " .,*' '-a " "t" ? ax"s STORIES VPE CONSTR.
by any applicant for a permit subjects the applicant toa civil penalty rgLTER-DRAIN&VENT-WATER (EA.) 4.00
Of not mare limit five hundred dollars($500)J:
0 I,as owner of the properly,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 Contractors License Law docs not apply Io 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
• himself or through his own employees,provided that such improve.
menti are not intended or offered for sale If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4,00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im. GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 2000 RES IND CON PB Oma,
0 1,as owner of tire .
e 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:T'he Contractor's License law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contents fursuch projects with a emtroctor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200}t/5.00
the Contractors License Law. TRACT NO. PARCEL NO.
0 lamesemptundcr Sec. ,B,&P.C.1ordiis WATER HEATER W/VENT 4,00
reason
Owner Date WATER SYSTEM_, J4 4.00 ACC.DATE ACC.FILE NO.
-
WORK ERS'COMPENSATION DECLARATION WATER TREAT(NG'EQUIP. t 4.00
affi
I hereby affirm that I have a certiGcale ofcomenl to self-insure; < (`stOer`n1O ZONING ENG.SITE NO.
or a c aRmam if Workers'Compensation Insurance,or cerfificd _
/I copy thereof(Sce.3800,LabC 1
T Policy Na. Company 0 " LA`L!LI
O L_Certifi¢ py hemhy furnished. I— FIRE SPRINK ENERGY T-24
z Z� 1] Ceni •A<p sis fit•d. with the city inspection.division. MISC. REFER TO ORD.
p nX, Applicant' _ Y❑ N❑ Y ❑ N❑
cc V-Ji CERTIFICA11:OP EXEMPHON FROM WORKERS' PERMIT ISSUANCE 6.00 Co— FLOOD ZONE A.L.U.C.
UJ �_ COMPENSATION INSURANCE PLG.CONTE. LIC.NO, PLG. /
1 O CI his section need net be completed if the permit is liar on¢ TOTAL / V Y❑ N❑ Y❑ N❑
Z hundred dollars($1001 or less.) r
U O 1 certify that in the performance of the work for which this Per I A r R E"`sE 'AA" uE FEE SUMMARY
mil Is issued,I Strait not en to an QTY. MECHANICAL*BPERMIT FEE
LL f P Y'any.person in any manner so as N i,
U become subject to the Workers Compensation Laws of California. r `
Ua Dolc Applicant BUILDING da xl f7
} m NOTICI. '00.APPLICANT: If,ufler making this Certificme of rix- ALTER OR ADD TO MECH. 4.00
Z coalition,you should become subject to lye 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 10p00C.F.M,) 3.00
CONSTRUCTION[-ENDING AGENCY AIR HANDLING UNIT(OVER 101000C.EM.) 5.00 SEISMIC FEE S�
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the perWnnance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00 . Uy
information is correct. I agree to comply with all city and county PLUMBING +
ordinances and state laws relating to building construction, and 130ILER-60MP(3H.P.Dr100,000B.T.U.) 4.00
hechy authorize representatives of this city to enter upon the BOILER-COMP (Over I00,000BTUI SEE FEESCH. MECHANICAL
ucerhy enlioncd property for inspection or
puity to.
(We) agree to save, indemnify and keep hornless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, Costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
Guy
my wa accrue against said City in conseyuence of the
gra m of his a nn,. O[�r'� MECH.CONT. LIC.NO. MECH.
�[(�1 �7 Z �QT TOTAL
, 1 Sign Erect ppleanl/Contractor f 8 Date `TOTAL:
OFFICECOPY -