3270 (2) CITY 01' CUPE.RI'1NO INSPECTION RECORD (Office Copy)
_3270 _ .10647 D Rosewood N_/S Dividers
• PERMIT 110, SANITARY DISI. NO. LOT 1.10. ADORPSS
Re-Model Property Services ' -
PROJECT OfdNER JOB SITE PHONE NO.
PERMIT ISSUED Date ELECTRICAL
ISui] dinr ___
5/25/83 Date Insp.
Electrical 5/25/83 Power Pole
I'lumhi lgr IInderround
llcchani.cal Rough Uiring
Temp. Cas/E1ect. Uaal.l .s _---
Solar Ceiling_
Fire Sprinkler Fixtures Int/Ext
Sign Rotors
Grounding
Misc. Temp. Power _
Other
FINAL INSPECTIONS Not Approved _
Date Insp.
r'°s -- PLUMBING
F,1. Date Insp.
Plnmbin . Backflow
'techanical Underground
Solar Underfloor _
Poni Partial. Rough
• Gradin , Rough Complete
Planning
DSolar Rough
F _
irere De t. Water & Insulation _
Health Dept. 'fain Drain
Puildin R/of/S Drain _
Other Gas
Other
BUILDING Not Approved
Date Insp.
Pad Certification MECHANICAL
Foundation Date Insp.
Pre-Ganite Underfloor S.M.
Slab-Membrane Ducts & Insulation
Bond Beam Fire Dampers
Underfloor Girders Fireplace _
Floor Steel Grease Duct & Ilood
Tiedowns One (lour Shaft _
Diaphrams Condensate Drain
Seismic Bracing Equipment Anchorage_
I1alls-1'anels Flues & Comb. Air
Frame Other
Lath Not Approved
11allboards Int/Ext.
Firewalls
Other
Not Approved
i
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LD ING PROJECT IDENTIFICATION IJ1.yk(. ERMIT NUMBER
BUILDING .lea #N APPLICATION & PERMIT '270
1O BUILDING - ELECTRICAL-PLUMBING-MECHANI
OWNER'5 PLAN CHECK VALIDATION
AME QTY. ELECTRICPERMIT FEE
ON
CONTRACT OH'sNAME OUTLETS-SWITCHES-RECEP 5.00/1.00
LIC.NO, LIGHTING FIXTURES 5.00/1.00 e0
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00 40ADDRESS
PHONE PANELS 5.00 DATED ATION
ARCHITECT SIGNS 6.Q0 P .CHECK FEE C.NO.
OR AYENGINEER n
LID.NO. SIGNS TRANS. 3,00 ,(
ADD Ess ENG' SPECIAL CIRCUIT 5.00 / PERMIT VA N
Of
APPLICANT
zIP EMP.METER OR POLE INS. 15.00 � (/ N110
ADDRESSMOTORS SEE FEE SCH.
OHEss
SERVICE CHANGE 10.00
S/YSf��
o o LICENSED CONTRACTORS DIiCLARA'I'ION
a Ea 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUAN E DATE
v, <w (commencing with SrOom 7000)of Division 3 of the Business anA BLDG. ELECT. PLG. MECH.
H D z Professions Code,and my license is in full force and effect. ❑ ❑ ❑ ❑
Q 0 n C License Class Lie.Number
Date Contractor
P: y 2 J
rc 4 OWN Ii R-B UI LD 1:R DEC LA RATION BUILDING PERMIT
E o a u INFORMATION
K
LL t- 1 hereby affirm that I am exempt from the Contractor's Lions MISC.- REFER TO ORD
W VALUATION S/FT.
F'u0J
Law fortheity following reason,
ywhich(Sec.
requirsa permit
ermit to construct,
Professions PERMIT ISSUANCE 6.00
EE �i,f Code:Any dryer county which requiresu p riot t nu ,lter,al, ep
2 ¢ 4 O improve,demolish,or repair any shuc[um,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. o O�
O or requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
e- w m U. he is licensed pursuant to the provisions of the Contractor's License
HZQ
Law(Chapter 9(commencing with Section 70001of Division 3 oftle
4 O Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE BOLL.
lib $ the basis for the alleged exemplidn.Any violation of Seclion 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects to applicant to a civil penally ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(55001.):
❑ I,as owner of the property,or my employees with wages us BACK FLOW PROTECT. DEVICE 2.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00 -
Code:The Contractor's License Law docs not apply to an owner at
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 50.FT,FLOOR AREA TOTAL ACREAGE
b
imselfre throughhisownemployers.Providedthatsuchimprove-
entsarenotint"f",1oroffcredforsalr.vP"...evcq the building GAS-EA.SVSTEM-11NC.40UTLETS 4.00
r improvement is sold within one year of completion,the ownerGAS-EA.SYSTEM-OVER 4 (EA.1 1.00 BULLDINC usE
uilder will have the burden of proving that he did not build or int-
rove forpowner of the
INDUSTRIAL WASTE INTER. 20.00 0RES IND0 0 PB 0
❑ L as owner of the property, he exclusively contracting with ❑
licensed Contractors to construct the pri hen (Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PAR CEL No.
to Professions Codon The Contractor's improv Law Juts not apply who �-+
to trownerofpropertywhobuildsor tons)vesthereon.and who LAWN SPRINKLERS-OV OVER 5IEA.1 1.00 3( 6 �y 3-3 s1
contracts for such censeprojects with a contmator(sl linnud pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT No. P Rc LNo.
. ❑ I am exempt under See. ,I MIX.for this WATER HEATER W/VENT 4.00
reason
Date rer�G' .OwWATER SYSTEM 4.00 Ace.DATE ACC.FILE NO.
WORKERS'CO 1PEN I ECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have u certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,Dip cerlfied ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No, Company
Q ❑ Certified copy is hereby famished. RE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed' with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y [] N[] , Y [:] N[:)
CC CERTIFICATE OF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.UG, .
LU COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG.
Q. O (This section need not be completed if the permit is for one TOTAL Y n N❑ Y ❑ N
D Z hundred dollar,IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL E. mit is issued,1 shall not employ any person in any manner so as to
O wbecome subject to the Workers'Compensation Laws ol'California.
y Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
>- m NOTICE 10 APPLICANT: If,after making this Certificate of I.x-
carat
x-
Z emption,you should become subject to the Workers'Compensation - APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Colic,you must forthwith comply with FEE .
U such provisions or this permit shall be deemed revokCd. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00 -AW
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE /
Lhereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work No which this permit is issued(Sec. - .MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U. 7.50 ELECTRIC
CTR I C vtivV'•d"�
I certlty that I hove read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
ordinances n correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances end state laws relu ting ni building construction, and
hereby authorize representatives of this city es enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby
coauthored property forinsp orth i purposes.
(We) agree to save, indemnify and keep hornless the Cly of Misc.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way34accrue against op City in consequen a of the
granting of this per iL MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Sign tore Of pplicaN/Con rift., Dam - - 415�/ro
OFFICE COPY