1781 TAPPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
1 ` - PER MI NU
BUILDING PROJECT IDENTI FICA APPLICATION & PE 7 V 1
� eUaowc - I }v(
AO
A �,' BUILDING-'ELECTRICAL-PLUMBING-MECHANICAL
0 NER'S /T �. ,a ` -I,,-� �r�S�B3/. PLAN CHECK VALIDATION
NAME /T j�' J /✓ al OTY. ELECTRIC PERMIT FEE
NAME"TRACTOR s IL UTLETS-SWITCHES-RECEP 5.00/1.00 00
LIC.NO. LIGHTING FIXTURES 5.00/1.00
ADDDRESSRESS oRs Oo
AD - APPLIANCES 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHEC FEE P.C.NO.
OR
ENGINEERLIC,NO, j%O /'1
SIGNS TRANS. 3.00 � - ///���////
ADDRESS END. PERMIT 5.00 PERMITvnuon//nTTo N/�)
ztP EMP:METER OR POLE INS. 15.00
APvucANr'a MOTORS SEE FEE SCH. (//Q/yS t•
AODREss
SFS S (/J SERVICE CHANGE 10.00 y
M o LICENSED CONTRACTORS DECLARATION F �1
< u u I hereby affnn that I am licensed under provisions of Chapter 9 IAA ATE
h < N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELE LG. MECH.
H o z Professions Code,and my license is in full force and effect.
z O'd' - License Class Lic.Number CI
I, Date Contractor
�I BUILDING PERMIT
uc w Q OWNER-BUILDER DECLARATION INFORMATION
w0 a r I hereby affirm that I are exent t from the Contract.,',License MISC.- REFER TO RD
i IL y y P VALUATION 5/FT.
H u 0 a Lw for the tbllowing reason(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00 6 cS
so Code:Any city or county which requires a permit to construct,alter. SQ O O
impnrve,demolish,or repair
tiny nruclura,prior to its Murree,also ELEC.CONTR. LIC,NO. ELEC. �SZ}p•
u requires the applicant for such"Hill to file a signed statement that - TOTAL PERMIT TO
w 2 he is licensed pursuant to the provisions of the Contractor's License _
Law(Chapter 9(com mencing with Section 7000)of Division 3 of the XCP-/OOC�--
- 4 Business and Professions Code)or that he is exempt lheretioin and OTY. PLUMBING PERMIT FEE
H the basis for the alleged exemption.Any violation of8cctfon 7031.5 STORIES TYPE CONSTR.
a � by any applicant for a permit suhj,,t,thu applicant to a civil penalty ) 4.00
.of not more than Ilse hundred dollars($500).): ALTER-DRAIN&VENT-WATER (EA.
❑ I,as owner of the progeny,or my employees with wages as BACKFLOW PROTECT. DEV ICE 2.00 OCC GROUP RES.UNITS
their sole compensation,will do tire work-and the structure is not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS FLOOR ROOF,AREA, 4.00 3
Code:The Contractor's License Lw docs not apply to an owner of
property who huilds or improves nmrcon,and wfio does ssicll work FIXTURES-PER TRAP 4.00 SO FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees, ls.If,ho that such improve-
mems are not intended hhisoroffered ces.provided
that,,themprong GAS-EA.SVSTEM-11NC.4OUTLETS 4.00
or hnprovement is sold within one year of contplction,the owner- GAS-EA.SYSTEM- A.1 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Oma.
prove for purpose of sale.). INDUSTRIAL WASTE INT 20.00 ❑ ❑ ❑ ❑
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044. Business LAWN SPRINK 1 & 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's Liana Law does not apply [�
to an owner of prolnrty who huilds or improve,Ihercon,and who LAWN SPRINKL 5-DV ER .) 1 AO
contracts for such pon,cl,with a cnt.,t.n,)licensed pursuant to
the Co ill a (or's Licenu Law. SEWER-SAN ITA .200ft/1.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec,-,tl.&PC.lit,ods WATER HEATER /VE 4.00 � 3 /a3
teawn
Dal, Owner WATER SYSTEM 4.00 ACC,DATE ACC.FILE No.
W'ORKERS'CO.1IPF,NSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby attlrnn that I have a cert hicxte nfconsonl two t-insure. ZONING ENG.SITE NO.
or a certifi vie of Workeri Compensation Insurance,or a evil be yrs
U. themof(Sec.3800,LAC.). N2
Policy No. Company
O ❑ CcUitled copy is hereby furnished. n �/� FIRE SPRINK ENERGY T 24
zp AooCeNifcd copy is fled with the ,try in,,Oion division.
licMISC.- REFER TO ORD. v
❑ v ❑ N❑
IM N CERTIFICATE OI'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.0 c.
LU > COMPFNSATION INSURANCE PLG.CONTR. LIC.NO. PLG. v 9[:] N❑ v O N❑
� Z (This section need not be completed if the permit is for one TOTAL
hundred dollars IS 100)or u,,A
U O 1 artity that in the perrunnnnee ol'the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued, 1 shall not employ any person in any nsamss•r so as to
U su
'become bject to the Workers'Compen,w Cron Lows of Culitornia. a
O w Datc Applicant BUILDING' �70s
a Pp ALTER OR ADD TO MECH. 4.00
} m
NOTICE TO APPLICANT: If,alter making this Certificate of Bz-
? ,motion,you should become suhjL,t ht the Workers'CompensationAPPLIANCE 4.00 PLAN CHECK
u
provisions of the Labor Code, yomust forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,D00C.F.NL) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 5.00 SEISMIC FEE � 7s`
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DU '2.00
Ore Perfonnanee of the ark for which illi,permit is ioumd(Sec, HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ,C.).
Lenders
Name HEATING UNIT IOV ER 0 '
Lenders Address ELECTRIC
I certify that I hme read this upphcutmn and slot,that the above VENTILATION FAN (SI L ) dv
information is correct. I agree to comply with all city and county PLUMBING 3 Q
ordinances and state laws relating to building construction, and BOILER-CDMP(3 H.P.ort 6
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,00OBTU)SEE FEESCH. MECHANICAL
abovementioned pinpcny for inspection pa gntas. �.
(We) agree to save, indemnify and keep hamiless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses whim PERMIT ISSUANCE 3.00 ,3 CONST.TAX
may in any way accrue against said City in consequence of lire
_ gmof tz m MECH.CONT. LIG MH,NO. EC
th �lJi TOTAL q TOTAL
Signature ol'Applothantruountractor Dale
OFFICE COPY - . - , -
CITUUG CUPERTINO INSPECTION RECORD (Off ice.Copy)
1781 _ 891 Tantau Ave. _
1'EPd1I'I N0. SANITARY DLST. 240. LOT NO. ADUIt1;S5
Remodel Lopresto
PROJECT OWNER JOB SITE.PIIONE NO.
PERMIT ISSUED Date ELECTRICAL;
Ell ildlnc 11-24-82 Date I.nsp.
Electrical 11-24-82 Power Tole _
I'Lumbing ll-24-82' Undc.F ,r_on nd
ilcchani.cal 11-24-82 Rough. Uirin 3 G1�_
"femp. Gas/Elect. 171I.I.S
Solar Ceiling '
FCre Sprinkler Fixtures Int/Ext
Sign Motors
Grounding
Hisc. Temp: Power
Other
FINAI. INSPECTIONS Not Apjiryved
Date Insp.
PLUMBING
Electric
Pliimbin , Date Lnsp.
Backflow
llechanical - Un�round
Solar Underfloor
Pool Partial Rough «-
Gradin , Rough Complete
' iannin Solar Rough
F -
ire Dept. 4later & Cnsulation
Health Dept. ".-fain Drain
Building R/of/S Drain
Other
Gas
Other
BUILDING Not Approved
Date Insp.
Pad Certification MECHANICAL
Foundation Date Insp.
Pre-Gunite Underfloor S.N.
Slab-Membrane Ducts & Insulation
Bond Beam Fire Dampers _
Underfloor Girders _ I;.ircplac_e
Floor Steel -Grease Duct & hood
Tiedowns 'One (lour Shaft _
Diaphrams Condensate Drain
Seismic Bracing Equipment Anchorage
Ilal.ls-Panels Flues & Comb. Air
Frame I-/I — Other
Lath Not Approved
Clallboards int/Ext.
Firewalls
Other
Not Approved
J
BUILDING
ELECTRICAL
PLUMBING
MECHANICAL
MISCELLANEOUS
i
CITY OF CUPERTINO
INSPECTION DIVISION
0 0 < 2 x m D D D D O E E m D D Z D D T D r O m ; c N " D
z D D 2 9 9 9 r D D D o x O m z z v 0
v y N N n y 9 3 2 y
m y y y D m m m m m Z Z C "{ D Jc m < O ° n y H m
9 r Z Z C D D 9 D 9 9 N m ♦ m j 9 tzii m p n D 3 D
Ij D O O o O Z O y m 2 �^ V 9 D m r 0 m N m
y R r n 9 9 < m D 9 9 H u H m O D n y n y m T RI ^ O
O Z 2 x m D m m m D Z 2 2 > < < `< D v 2 m D Z
O n D y y y JC z u y m 9 Z r y 9 n m
9 u Z y y O CC C x y m m D r r f y x 9 C Z O C 9 y y m O
0 2 m O 2 Z D 9 9 m O 3 O 9 m C n n m
9 2 O f ~ O Z GZl `e` �< y `� 9 m m = m 90 y O m m a y
8 0 2 9 8 _ 0 m > O m p 0 Z v 1 i v m z m �' o O d
p n C Z p < m 0 y 9 m m
o x v c y m m m Z m a 2 'y
pp r 8 C trtro bb m L y a <_ H a N D n 3 y H
3 m r •� p-.
m m r \ z Y
r C C D m ti
° n �O m b
O
D n 0 � _
r � x
m m m N R
m m m
m m m
L]
m ; m m y m y m Lam]
R m C m m my C
x ; i o
O 2 Z 9 T x Z m
"�`c
c
o
n O n m m O m
i
y
z " [
❑m
x