3283 (2) CITY Op CUPFIT7NO INSP-ECTIM! RECORD (Office Copy)
_32,13 _ _10656 Rosewood TI/S Dividers_
• PI:I'JII'r PTO. SANITARY DIST. NO. LOT NO. ADI)PESS
Re-Model Property Services '
PROJECT OWNER JOB SITE PHONE NO.
PERPIIT ISSUED Date ELECTRICAL
Buildi.np _ 5/25/83 Date Insp.
Electrical Power Po_I_e_
1,t1mhing Under ,round ---- ----
Mcchanical Rough Wiring --
Temp. Cas/Elect. Flal.7.s __---
Solar Ceiling
Fire S rinkler Fixtures Int/Ext
Sign Motors
Grounding
IUsc. Temp. Power _
Other
FLNAL INSPECTIONS Not Approved _
Date Insp.
G s PLUMBING
Electric Date Insp.
Plumbing Backflow _
Mechanical Underground
Solar Underfloor
Pool Partial. Rough
• Gradin , Rough Complete
I'lianning, Solar Rough _
Fire Dept. Nater & Insulation _
Health Dept. 'lain Drain
Building R/of/S Drain _
Other Gas _
Other
BUILDING Not Approved
Date Insp.
Vad Certification MECHANICAL
Foundati.on Date Insp.
Pre-Gunite Underfloor S.M.
Slab-Hemhrane Ducts & Insulation
Bond Beam Fire Dampers _
Underfloor Girders Fireplace
Floor Steel Grease Duct & Hood
T:iedowns One Hour Shaft _
D.i_aphrams Condensate Drain
Seismic gratin{; Equipment Anchorage -- _
Ualls-Pancls Flues & Comb. Air
Frame Other
Lnth
Not Approved
Uallboards Int/h:xt.
Firewalls
Other
. Not Approved
-APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
IBUI LDING PROJECT I DENTIFICATI ON ERMITNUMBER
Buaoirvc APPLICATION & PERMIT 2 8
6 ILDINs
�S IJP S BUILDING — ELECTRICAL—PLUMBING—MECHANI
OWNERS - - PLAN CHECK VALIDATION
ME ELECTRIC PERMIT FEE PAID
NAME ATR OUTLETS-SWITCHES-RECEP 5.00/1.00
LIC.NO. LIGHTING FIXTURES 5.00/1.00 MAY 2 5 1983
CONTRACTORS
ADDRESS APPLIANCES-RESIDENTIAL 4.00 +
AOORE ' CITY OI CII�JQ'..'yy``I nn
PHONE PANELS 5.00 DATE OF APPLnCATION
ARCHITECT - SIGNS S.QD PLAN CHECK FEE P,C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00 '
ADDDRESS ervc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
ADDRESETNrs MOTORS SEE FEE SC .�/iI?�o�
r SERVICE CHANGE 10.00
0 00 LICENSED CONTRACTORS DECLARATION
< i w I hereby affirm that I am licensed under provisions of Chapier 9 ISSUANCE DATE
¢ i, (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w i Professions Code,and my license is in full force and effect. •❑ ❑ ❑ ❑
oi wt o License Class Lic.Number
m r Date Contractor
a m BUILDING PERMIT.
¢ ¢ w ¢ OWNER-BUILDF-R DECLARA'PION 1
o a w INFORMATION
`i ; w r 1 hereby 011'inn That I am exempt limn IIIc Contractors License MISC.— - REFER TO ORD
w m (Sce.703 vgLUATION $/FT.
5 Law fornycit llorcountywhichrequir1.5,ermit ess tocnd Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requiresa permit to consuanc,also
2 S¢ p improve,demolish,m repair any slntClum,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
to
LL requires the applicant for such permit to file a signed statement(hat TOTAL PERMIT TO
K
$ he is licensed 9(co m to the provisions of(he Contractors License ./�)
F2i
Law(ChapterProfessions
Codeng)or Section is 00)exempt
the
and
9 i o Business and Professionsxempt or thin he is exempt therefrom mal QTY. PLUMBING PERMIT FEE
w r- $ the basis for the alleged exemption.Any violation of Section malty STORIES .'TYPE CONSTR.
d ; � by any applicant fire permit dollars(heapplicunt toacivil penally ALTER-DRAIN -WATER MA.) 4.00
of not mom than five hundred dollars($500j.):
❑ 1,as owner of the property,or my cnfployees with wages as 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,AREA,COND. 4,00 -
Code:The Contractor's License Law does riot apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 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 burden.(Proving that he did not build nr im . . .
RES IND CON PB omnr
Prove for Purpose ol's:de.)' INDUSTRIAL WASTE INTER. 20.00 ❑ ED F-1 ❑ ❑
❑ 1,as owner of the property,ant exclusively contracting with
licensed contracture to constmd the project(Sec.7044, Business LAWN SPRINKLERS-1 INC 6 V.B. 5.00 ASSES so SPARCELNO.
and Professions Code:The Contractor's License Law does not apply
(n an owner of Property who builds or improves(hereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 p ``
contracts forsueh projects with a contractors)licensed pursuant to —
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt tinder Sec. B.&P.C'for(his WATER HEATER W/VENT 4.00
reason
Dote --� Owner. _ G_ WATER SYSTEM .4.00 ACC.DATE ACC.FILE NO.
c)
WORK iRS'COMPENSf1' N ECLARATION WATER TREATING EQUIP. 4.00 -
I hereby affirm that I have u certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Seu.3800,Lab.C.). '
Policy No. Company
Q ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is tiled with the city inspection division. MISC - REFER TO R RD
— O Applicant E O V N v N
CC — C17HLWICA'I'F OF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.U,C.
LU D COMPENSATION INSURANCE PLG.CCNTR. LIC.NO. PLG.
D' O (This section need not be complclCd if(he permit is for one TOTAL Y❑ N❑ V ❑ N❑
Z hundred dollars($100)or lest
U O 1 certify that in the performance of the work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued, 1 shall trot employ any person in any manner so as to
O L) become subject to the Worken'Compensation Laws of California.
a Date Applicant ALTER OR ADD TO MECH. 4,00 BUILDING / So
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex- t
F ? emption,YOU should become subject to(he Workers'Compcnsutlon APPLIANCE 4.00 PLAN CHECK
provisions of ilia Labor Cade, you nowt forthwith comply will) FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE /5_0
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued IS", MICROFILM
3097,CieC.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.M50
Lender's Address ELECTRIC '
I certify that I have .it this application and state that the at)ovu VENTILATION FAN (SINGLE) 3.00
. information n correct,l I agree to comply with all city and cnunTY PLUMBING
ordinances and state laws relating To lujilifing construction, and BOILER-COMPO H.P.or 100,000 B.T.U.) 4.00
hereby imilentioriic representatives for ins of ([Its city es enter upon Ihu 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
may in any way accrue against said ty in consequene If he
granting of this per tit. /ra MECH.CONT. LIC.NO, MECH. TOTAL
TOTAL
SigQ�
ly n re ofilApplicanc t/Contrac of Un '
OFFICE COPY