12289 POST THIS CARD NEAR FRONT OF BUILDING
PF_RMIT NUMBER
CITY - OF' CUPERTINO.'
INSPECTION DIVISION 1 289
JOB INSPECTION RECORD,
n ' „PERMIT EXPIRATION '
JOBADDRESS o �„(LL� �•1'% UNIT# LOT# _
PERMIT EXPIRES IF WORK
OWNER - R TOR 'I IS' NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION - ANCE•OR 180 DAYS FROM
LIFER
LASTCALLED INSPECTION. ' '
PREGUNITE PERMIT 9� VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB' {
PLUMBING
ELECTRICAL
. - ISSUANCE GATE
MECHANICAL. " - , BLDG.,,l ELECT. PLG, MECR.
El
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
WOOD FLOOR - ,• INFORMATION
VALUATION. $IFT. -
PLUMBING
MECHANICAL - • 'c
ELECTRICAL - PERMITTO
FRAMING \:.
INSULATION „ , STORIES, TYPE CONSTR.
OCC.GHOUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF' , SO.FL FLOOR AREA TOTAL ACREAGE_
IAPHRAGM ' -
IAI'-'•mss BUILDING USE ,
RES IND CON;, PB Otner
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑ ❑ ❑
ROUGH
.,ASSESSORS PA R CEL NO.
' .
PLUMBING
GAS TEST _ TRACT NO:, .p PARCEL NO
. MECHANICAL - - -
'ELECTRICAL - - FINALS DATE INSP. Acc.Dare Acc.FILE NO.
FRAMING y:.(��J,, SAN
INSULATION PLUMBING _ ZONING ENG.SITE NO. -
GAS -
MECHANICAL - - • FIRE'SPRINK- ENERGY T.24..
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y ❑ N.❑ ❑ N❑. -
LATH—INTERIOR —�J,� ELECTRICAL, " .FLOOD ZONE ',A.L.U,C.
LATH—EXTERIOR FIRE DEPT. ,Y❑ •N❑ - Y _N❑
SHEETROCK „ GRADE FEE SUMMARY
SHEAR INTERIOR 113UILDING
;q,_•
. SHEAR EXTERIOR I TEMPORARY APPROVALS - BUILDING �/•
FIREWALLS" ELECTRIC PLAN CHECK . •;+
GAS..' " - FEE'.
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE y
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL.IS SIGNED By BUILDING INSPECTOR. .MICROFILM -
ARRANGE FOR INSPECTION BY PHONING 252-4505 ELECTRIC
F ONE WORKING DAY BEFORE.REQUIRED INSPECTION. PLUMBING'PLEASE GIVE JOB ADDRESS WHEN PHONING. ''
- SEE PERMIT FOR-EXPIRATION DATE:- MECHANICAL
IMPORTANT! CONST.TAX.
PLEASE READ REVERSE SIDE BEFORE TOTAL wl
CALLING FOR FINAL INSPECTION.'
OFFICE COPY ', ��_4
APPy.ICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT /�/� /�
ADDRESS,,- -/'/Olt
O b(J - O BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 2289
OWNS 'S - Od PLAN CHECK VALIDATION
NAME /y \ QTY. ELECTRIC PERMIT FEE
/ &//r el PHONE LI /
r.v`
NAMERACToOs - UTLETS-SWITCHES-RECEP 10.00/1.00
94
M Turn,'+r uc.NO.' LIGHTING FIXTURES 10.00/1.00
Offs
ADDRESS APPLIANCES-RESIDENTIAL 4.00
ORE55 II'' '�
( W�tM G 'k PHONE SG PANELS. 10.00 DATE OF APPLICATION
OR
ARCHITECT • PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE
ENGINEER -
uc.No. - SIGNS TRANS. 3.00 '
ADDRESS ears. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 P
ADDRESS MOTORS SEE FEE SCH.
AW
ADDRESS - /�
SERVICE CHANGE 20.00 C 1 r'y /0 /fib
wo O LICENSED CONTRACTORS DECLARATION
a i W I hereby affmn that I am licensed under provisions of Chapter 9 DATE
a a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MUCH,
F,m i Professions Code,and my license is in full force-y eft t. ,❑ 1:1
❑ ❑
O to - License Glasy ' Lic.Number J /
Z z - Date /-a 17 Contractor er I t
a x f BUILDING PERMIT
¢ wOWNER-BUILDER DECLARATION I - INFORMATION
F LL w I hereby affirm'that'I am exempt from the Contractor's License MISC.- REFER TO ORD,
F I� oJ Law for the following reason. 7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION g/FT.
Code:Any city or county which requires a permit to construct,alter, L
2 La ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
iO u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w $w he is licensed pursuant to the provisions of the Contractor's License
Fi> Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
S H o the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
i m by any applicant for a permit subjects the applicant to a civil penalty .,ALTER-DRAIN&VENT-WATER IEA.) 5.00 .
of not more than five hundred dollars($500)-): '
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCC.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. 5.00
Code:The Contractor's License Law does not apply to an owner of '
- property,who,builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SD.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
r or improvement is sold within one year of completion,the cover, - GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE builder will have the burden of proving that he did not build or im- RES IND CON PB Omar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 El El El ED 1:1❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the-project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. '6.00 ASSESSORS PARCEL NO.
and Professions Code:The Conhacfor'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 for such projects with wcontractons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
-❑ l am'exempt under Sec. ,B.&B.C.for this WATER HEATER W/VENT 6.00
reason-
Owner - Dare WATER SYSTEM 5.00
ACC.GATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, - -
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy there o,�f((�S�gp.�1�9pp�Lab.CJ. I�IJ
Policy No..f-rT`'ICyer7,pfsny 7-"e 11IT"_ _ .
Q. ❑ Certified copy is hereby furnished - FIRE SPRINK ENERGY T.24
Z Z ❑ Certifitd copy is Bled with the City inspection division. MISC.- REFER TO ORD.
APD Ca[ 10.E -il /1,y+-�- Y ❑ N❑ Y ❑ N❑
~ in PERMIT ISSUANCE 10.00
LU CERTIFICATE COMPENSATION
INS FROM WORKERS' - FLOOD ZONE 1A.L.u.c.,
W � " COMPENSATION INSURANCE PLG.,CONTR. . `LIC.NO. PLG.
CL
Z (This section need not be completed if the permit is for one TOTAL v❑ NE] Y ❑ .N[:]hundred dollars($100)orlesS.)
0 0 I certify that in the performance of the work for Which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL f mit is issued,I shall not employ any,person in any manner so as to
U become subject to the Workers'Compensdtion Laws of California.
i Date Applicant ALTER OR ADD TO MECH., 5.00 BUILDING 3,' -I-y-
>_
�
} US NOTICE TO APPLICANT: 11,after making this Certificate of Ex-
F2 emption,you should become subject to the Workers'Com pensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with - FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10)000C.F.M.) 4.00
'CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE S-0
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5,00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). - HEATING UNIT(TO 100,000 B.T.U.) 6.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
/ \ Lender's Address - ELECTRIC
• I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
-uhramees and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
\� hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCM. MECHANICAL
es
(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 10.00 CONST.TAX
may in any way accrue,against said City in consequence of the
granting of this permit. MECH.CONT. LIC.NO. MECH.
1 �� 6L
6 TOTAL TOTAL 39 �O
Signature ofA a nt/Contractor Data
OFFICE COPY , ^�,