7210 (2) CITY OF CUPERTINO INSPECTION RECORD c/
(OFFICE COPY)
10&F6
Lsr-NO.
B lm �� o`�utiu�evtee GUde)y
OWNER
PERMIT ISSUED DATE ELECTRICAL DATE INSP.
ui 1n
ctric
Plumbing Power Pole
anica r un
Te Gas . ecou irin
o ar 4 s
ire r er ei in
Sign fixtures int/Ext
tors
Misc. rounin
mower
Other
FINAL INSPECTIONS DATE INSP, Not rove
Gas
ectric
Plumbing PLUMBING DATE INSP.
Mechanical
• oar Backflow
00run
r in oor
Planning arti ou
Fire D=t. Aougn U iete
Health Dept. Solar � uoh
uiIding Water *& Insulation
erMain .urain
7767=aln
as
Other
BUILDING DATE INSP. Not Approved.
Pad Certification
oun ation ELECTRICAL DATE INSP
re- unite
Slab-NL-mbrane Underfloor S.M.
bond eamcts ns ation
Under±loor Girders Fire DaMers
Floor tee i eplace
ie owns Grease Duct 6 Hood
is rams One Hour Shaft
eismec Bracing Condensate ITrain
Wa- s- ane s uiAn ent orae
Frame ues r
Lath t er
��3 oar nt xt. of rove
Ot era s
etNApproved
.,,1aPPLICANT•T0 FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
- - _ PERMIT NUMBER ;
BUILDING PROJECT IDENTIFICATION APPLICATION SE PERMIT . 1/`// 1
BUILDING `• 2'10
'•'" " PDDIIE55
O � ' -' 'BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
OwNE 5 - - PLAN CHECKV LIGATION
NAME CITY. ELECTRIC PERMIT FEEq)��
IG CC� PHONE�S 13.4N' J� ��/I�j ( •�4
CONTRACTORTORS'SI/
NAME � � ^� r� UTLETS-SWITCHES-RECEP 5.00/1.00
Y ' 5li G �4
vI �Lic.No.J �' ' LIGHTING FIXTURES 5.00/1.00
coNTRACTona APPLIANCES RESIDENTIAL 4.00
'ADDREs �/� -
QONE' /-61-Ii� PANELS 5.00 • GATE OF APPLICATION
ARCHITECT, SIGNS 6.00 PLAN CHECK FEE P.C:NO.
ENGINEER
LC.NO, 1 SIGNS TRANS. . 3.00
AARCH.OR DDRESS ENG. ` SPECIAL CIRCUIT '5.OQ PERMIT VALIDATION "
A ZIP, EMP.METER OR POLE INS. 15.00'
ADDRESS
APPLICANT'S - MOTORS SEE FEE SCH. �/�.-Ci "a e;V}
� '� '� - ' I "
• ' SERVICE CHANGE 10.00
woo LICIiNSEU CONTRACTORS DECLARATION
a uw I hereby affirm that I am licensed under provisions of Chapter 9 . . ISSUANCE DATE
N a a ( o n crag with'Section 7000)of Division 3 of the Business and BLOC. ELECP, [PLG. tMECH.
m Pnl ss' Co.�y yRy �y��� Lv nfull l Vy1p��t t 01n(' I�—t
i O L T License Class_tso eqc.Numbei—J_Y`-'� .n - ❑ ❑ ❑H I—f
9 1- w Univ z.' CnntmmG "
a m -��T J °`'' �.�T - ! BUILDING PERMIT
a o d OWNER-BUILDER DECLARATION . ' •• INFORMATION
IL
; r 1 hereby A'rm thut I am exempt from the Contractor's License MISC.— REFER TO OR
pF .. O.j Law for the Billowing reason.(Sec.7031.5'Business and Pro fessions pERMIT,ISSUANCE 6.00 1 VALUATION •.. $/FT.
, gym m � � 'Code:Any'city urrormty whichrcquiresapermitioconstruct.liBcq
¢ R ¢ O 'improve,demolish,or mpmr any Structure,prior it its issuance',also ELEC:CONTR." LIC.NO. TE LEC.
I
w m u requires the applicant for such permit to file a signed!statement that TOTAi PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License /
ca z r Law[Chapter 9(commencing with Section 7000)of Division 3 of the
4 0. Business and Professions Code)or that he is exempt therefrom and QTV:
PLUMBING PERMIT Q
. FEE - `
•sow•$ the basis for the alleged exemption.Any violation of Section 7031.5 1 STORIES TYPE CONSTR.
n ; by any applicant for a permit subjects the applicant moa civil penalty ALTER- .)(EA
.14.00
of not more than five hundred dollars($500).): '
❑ 1,as owner of the property,or my cmployces.with wages as - BACK FLOW PROTECT.DEVICE 2.00 I)=GROUP RES.UNITS
their soWcompensation,will do the work,and the structure is not
intended or offered for snle,(Sec. 7044, Business and I'rol'essions DRAINS-FLOOR,ROOF,AREA,COND. 4.00"
Code:'the Contractor's License Law does not apply to an owner of
property,who hnllds of ImpTOVCS 1110MOn,and who does Such workFIXTURES-PER TRAP 4.00 SQ FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
memsare not intended OrOffered 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- GAS'-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
RES IND CON PB Other
Prove fors owner ofsale.p � INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑. Cl
❑ d as owner of the property,he exclusively project
contracting with
am]Pedcontradod m construct the project(Sec.7044, Easiness LAWN SPRINKLERS-1'INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and l'6wncr of property who
builds o improvense s thercc5 not who
' pply
to an owner ol'vrovprly'who builds or improves lhercon,and who LAWN SPRINKLERS-OVER 5IEA.)'' 1.00 '
contracts for such projects with a emntraetor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8,00 TRACT NO. PARCEL NO.
{R ' ❑ Lune,xmnpt under Sec. ,B.AP.C.1lmihls WATER HEATER W/VENT 4.00 s
reason
` Owner Dame WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
";WORKERS'COMPENSA'I'ION UECLARA'fION WATER TREATING EQUIP. 4.00
1 limcby'afOnn that 1 have a certificate of consent to selfrinsure, 1 ). - 20NING
' or d certificate of Workers'Compensation Insurance,or a certified 1 • ENG.SITE NO,
copy treteWp�($$LI.yy..3 (1Q Lan C:). +
Po�liy Y Nn.'Li('a.l I'<limpanY cJ9 -
0 ALN,Ce tilled copy is lireby furnished as
Z z ❑ Certified file wtit. -it nspp hon division FIRE SPRINK ,ENERGYT2<
O Applic i - _ MISC.- - REFER TO ORD, r ❑. . N.❑ r ❑ N❑
~ rn • ' PERMIT ISSUANCE 6.00 " FLOOD ZONE A.L.uc.
_ CF.RI' ICA ILOI IS%IiMY1[ON IrROM WORKERS' naa C�•
LU COMPENSATION INSURANCE PLG:CONTR. LIC.NO. �' 'PLG.-
CL O ihids•sectihin need not be completed if the permit is for one TOTAL , ..y❑ N❑ y ❑ % N❑
D Z. h andred ddlars(S 100)or less.) - -
U O - 1 certify that in the performance of lite work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
...•LL F alit is issued,I Shall not employ any person in any manner so as to -
U hecome subject iodic Wukcrs�Compensation Laws of California. '
Date - Applicant - ` BUI LDING,' ^^-'7�� e�
" U a ALTER OR ADD TO MECH. 4.00 (/
} m NO'fICG TO APPLICANT: If.I L subject
to O , this Certificate lc of Ex-
F Z provision you should become subject to the Workers'Compensation APPLIANCE _ 4.00 PLAN CHECK
provisions of Ihd' Code, you most forthwith cool Ply with -FEE
U such provisions or,this
hiS pe Permifshall be deemed revoked. - AIR HANDLING UNIT(TO 10,000 C.F.M.) 3.00
CONS'I:RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE
I hereby ulfirn that there is'a construction'lending agency for EXHAUST HOOD (WITH DUCT) . ' 2.00 -'
lire performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L. HEATING UNIT(TO 100,000 B.T.U.) 4.00 a„
Lender's NamAddress HEATING UNIT(OVER 100,000 B.T.U.)7.50
Leader's ss ELECTRIC
` F- 1 L rl'fy thm 1 tin read ihhs avvheation and s1aLL Ihd)tit aboveIrVENTILATION FAN (SINGLE) - . 3.00. Information is correct I agree to nti comply with all city acourtly PLUMBING
t i r f anus and scam Ihws mlulhnb to'buddirb onstr tI n, am!
BOILER-COIZI H.P.or 100,0008.T.U.) 4,00
hereby authorise epe,emiltives of•this city to'•nter upon`ihe BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL '
ahovementomed proverty for inspection purpoms. -
OV,) agree to save, indemnify and keep harimics5 the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, coats and'expenses which .CONST.-TAX
may in any'way.ac5DI, agni 1 Said City in consequence of the PERMIT ISSUANCE 3.00 _
grain in fm11 venni MECH.CONT. LIC.NO. MEER. ay��
Is TOTAL v V
` ,b.',: zlxs,,,' TOTAL
nu arc of t/Con[mcmr ate
OFFICE COPY