5770 (2) CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
5770 21271 Stevens +Creek Blvd.
MIUM
Innveltterior Improvement Stoneson Deopment _
�k�N
PERMIT ISSUED DATE "ELECTRICAL DATE INSP.
Building
Electrical
RUNink Power Pole
Mical rr�roun
Temp as ec ;� Ugg i W�.ring
bolay ells
Fire Sprinkler ei m
Sign
ixtures Int/Ext
otors
Misc. row irr -
emp Power / _-V-Fi
Uth
er
FINAL INSPECTIONS DATE INSP, of rove
Gas
Electric
Plumbing PLUMBING DATE INSP.
—.Mechanical1, _
�o ar Backflow
0o Underground
Grading r oor
Planning Partial Rough16)G�
Fire t. 1 _ g4 u i o ete
eat et. oar u
ki in ater ' Insulation
er 1 Main Drain
oMain
Gas
Other
BUILDING DATE INSP, Not Approved
Pad Certification
oun anon f ELECTRICAL
DATE INSP.
re- ite
a - em rane Underfloor S.M.
Bond earn ctsnsu ation 0
Underfloor Girders Fire Damers
Floor Steel Fireplace
ie owns brease 1juct & Hood-
Diaphrams One Hour Maft —
eismec bracing Condensate Drain
Tt�s- ane s unt Anchorage
Frame o- omb. Air
at Other
allboards lnt/Ext. Not Approve7
F'irewa s
Other
Net Approved
;APPLICANT TO FILL IN INFOR .TION WITHIN RED LINES - USE BA POINT,PEN ONLY.
PERMIT NUMBER
BU I LDING PROJECT IDENTI FICATI APPLICATION & PER
ADDRESS
Tom$ K ✓� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 5770
OWNER'S- ofiLO/x.I - PLAN CHECK VALIDATION
• / �a DTV. . ELECTRIC PERMIT FEE '
I NTIIPCiUri'S
ROME
- ','
I AME OUTLETS-SWITCHES-RECEP' 5.00/1.00
uc.NO
-3 _/ LIGHTING FIXTURES , -- 5.00/1.00
r .
foNTRAc]oR's
FAPPLIANCES-RESIDENTIAL 4.00 .
y OORES //-.
14444.7 .ly PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6,00 PLAN CHECK FEE P.C.NO.
ENGINEEn A
5: IIAYLlc.No.` 90o SIGNSTRANS. 3.00 `
ARCH,oR ENC. PERMIT VALIDATION
j ADDRESS '/ SPECIALCIRCUIT "5.00
�T. R L zIP 17 EMP..ME_TER OR POLE INS. 15.OD
APPLICANT'S ' MOTORS _ SEE FEE.SCH. ('L+
ADDRESS
�W/ ,l
�b' / S - L✓J�• SERVICE CHANGE 10.00
00 LICENSED CONTRACTORS DIiCLARATION _ A
I hereby affirm that I um licensed under provisions.1 Chapter 9 - ISSUANCE GATE '
Ha (commencing with Section]000)of Division 3 of the VUR neIS and BLDG. ELECT. PLG. MECH.
H 0z lie ferment Cod d my license is in full fo " n e
Oz O u, Liccnsu C�hIa'IIss_ Lic.Numbs -
O �.� Uate_1q(V Contractor El
a m s `11 -�� tt BUILDING PERMIT
¢ a a OWNER-BUILDIiR DECLARATION
o a o - - INFORMATION
s w,; N I hereby affirm that I am exempt from the Contractor's License MISC,- REFER TO ORD
u o j Law for the following reason.(Sec.]031.5,BusinasanJ Professions' VALUATION $/FT.
H - PERMIT ISSUANCE 6.00 / G DAID
Coda Any city or county wh icy structure p riot to consua ce,also fQ a O�1-b
Q Q a IInpIDVC,fIe1110hr11,or repair any rlftlClUm:prior to Its issuance,¢ISD ELEG CONTR. LIC.NO.. ELEG.
or
D'u requires the applicant for such permit to file a signed statement that TOTAL VE M T T
A w m he is licensed pursuant to the provisions of the Contractor's License �s D K gA
h H z i
Law(Chapter 9)commencing with Section 7000)of Division 3 ofthe - f).�e
4 o Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT 'FEE
ce the basis for the alleged exemption.Any violation ofSectun 7031.5 STORIES TY[4ffNSTR. ,
_ by,any applicant fora permit sub)ecls theapplicmlt toacivilpanalty ALTER-DRAIN (EA.) City of uper1l10
of not mon titan five hundred dollars(5500).):
❑ I,as owner of the property,or my employeeswith wages as BACK FLOW PROTECT. DEVICE 2.00 Oce.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 Contractor's License Law does riot apply to an owner of
prnptrty Who builds or improves flumeon,and who does titch work FIXTURES-PER TRAP 4.00 SQ.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
munisarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner,
u builder will have the burden of proving that he did not build or im- - I GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
Prove for purpose ofsale.)., - RES IND CON PB• Other
.❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. -20.00 [:] ❑ 0 . O ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPR INKLERS-i INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:"file 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
contracts forsuch projects with acontractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00
the Contractors I.icensc Law. TRACT NO. PARCEL NO.
Pen
OR
I am exempt under Sec. ,BAP.C.for this WATER HEATERyW/VENT
• 4:00
Owner ' - Date WATER SYSTEM .. 4.00 ACO.GATE ACC.FILE NO,
WORK ERS'COMPENSAil'10N DECLARATION WATER TREATING EQUIP. 4.00 _
if hereby Affirm that I have a certificate of consent to sell-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
L IY there o ft$y�B00 lab.t:J -
P hc�N .-(Ck*_F( mpany G "qS 7•�''
Q /tT l:eRR red opy hs hereby furnish ed - FIRE SPRINK ENERGY T-24"
.Z ' ❑ C'r died coP fh1•d with th b'y 'tsl e l a division. MISC.- REFER TO ORD.
U Apphca t _ Y ❑ N� V Q N�
cc h ( O PERMIT ISSUANCE . 6,00
.d' - Clift IPICATE0 Iih.Ml'TION FROM WORKERS' FLOOD ZONE A.L.U.C.
LU � COMP. SA'IION INSURANCE PLG.CONTR. LIC.NO, PLG.
CL 0.` ('])us section need not,be'colnpleted if the permit is for one TOTAL - Y❑ N❑ Y [:] ❑
'N
UO hundred dollars(5100)or less.)
I certity that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LLf- :� m8 is Issued,I shall out employ any person is any manner so as to
U become subject to the Workers Compensation Laws of California.
�U'0. Date Applicant " ALTER OR•ADD TO MECH. 4.00 BUILDING 3j' /Y
} W NO]ICE TO;APPLICANT:"It,after making this Certificate of six- _
? empti.e.you should bre mne subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor.Cole, you Must forthwith comply with FEE
•.U such provisions or this permit shall he deemed'revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00 -
CONSI!lOJC`l1ON.LEMINGAGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE 7(0
I hereby affirm that there is a%onrtrucllon lending agency for EXHAUST HOOD (WITH DUCT) 2.00 -
thc performance of the work for which this permit is issued ISec MICROFILM
3097;Civ.C.). _ HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVERA 00,000 B.T.U.)7.50 - -
Leader's Adder, - ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 ,
inhormation is correct. I agree to comply with all city and county PLUMBING
ordin:mces and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.).4.00
•
hereby authorise representatives of this city In tees upon the BOILER-COMP(Ove,I00,0008TU)SEE FEE SCH. - MECHANICAL
'_¢have-mentioned property for inspection purposes.
(We),agree to save, indemnify aM-keep harmless file-City of MISC.- REFER TO ORD.
C.fwnimo against 11a6111tres,judgments costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX `
may i my. try recent agoras s� by in c, nseq uenw if the -
crmt MECH.CONT. LIC NO. MECH:
7 - S ., TOTAL
Sh nature ofYip hcant/Contracmr p e TOTAL
A.
/
OFFICECOPV -, -