12413•
tr 'POST'THIS CARD NEAR FRONT -OF BUILDING
--E
'
CITY UPERTINO
-PERMIT NUMBEF If
12413
'INSPECTION'DIVISION.
,
JOB INSPECTION RECORD
i
PERMITcEXPIRATION
JOB ADOR Ess �D�S�' C4,,c 114Lz' UNIT#- LOT.#
PERMIT EXPIRES-IF:WORK
OWNER .,,, -.C:Q: tO OW ' .CONTRACTOR -� . rQrl w��/'aAµr7,
IS NOT ,STARTED WITHIN .
teo DAYS OF PERMIT'ISSLI `
:; ANCE OR. 180 DAYS FROM'
LAST CALLED INSPECTION-
INSPECTIPW DATE INS ECTOR
IIIIISPECTION RECORD
FOUNDATION -'L "`
G0.14aL9c '$I0. 5 ;c - O m-2yr8> C,
UFER.:-
FREGUNITE.• , - '.. '�
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•'• PERMIT VALIDATION
•• . ISSUANCE DATE Ix'
POUR NIO C ETE UNTIL ABOVE HAS BEEN SIGNED
' .'. UNDERGROUND/ SLAB
PLUMBING .
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ELECTRICAL•: ,
MECHANICAL { " " +
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BLDG ;
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ELECT.
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DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED
BUILDING PERMIT
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INFORMATION
` A'WOOD'FL'OORI
VALUATION f
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INSULATION :.„'�'. . _
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i- STORIES
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;YPEONSTR.
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'.ARES. UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
I
FT. FLOOR AREA
TOTAL ACREAGE -
DIAPHRAGM •,�'
T ”
auaDlNG USE
RES,"'IN0 CON ' PB Ciheri
❑ "El ° ` E]�' 1:1 ❑"'
APPLY NO ROOFING UNTIL ABOVE'HAS BEEN SIGNED
'ASSESSORS PARCEL NO.
" ROUGH
PLUMBIN
GASJEST "t' „`.
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TRACT NO :...
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PARCEL NOL,.
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MECHANICAL
ELECTRICAL -
- FINALS DATE INSP.
-,ncc. UPI EAcc.F
aE No.
: /
FRAMING _ .;.. (r -d{ - .
$AN # � U�'
,3
ZONING -'!
ENC. SITE No.
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INSULATION -1v
PLUMBING +
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GAS '• �', ✓ �� _e”lwo
FIRE BPRINK'
ENERGY T-ZO
MECHANICAL
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COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
HEATING' 36•�
FLOOOZONE
+;'.'E
"- v0 N�
'. AL.0 C^'�
, ;,V L7,."N.0
LATH -INTERIOR -l�,- -
',�•'
ELECTRICAL - r,:�
LATH -EXTERIOR` _ _
FIRE. DEPT •. . • it-
SHEETROCK,-- -
'
GRADE' -
FEE SUMMAR
SHEAR INTERIOR '7 •.BUILDING
-s" 'I '.r
BUILDING �,"
,lY'
t�l(,�"
I SHEAR EXTERIOR
TEMPORARY APPROVALS
FIREWALLS'ELECTRIC"
PLAN CHECK
FEE '•
,;.
GAS
SEISMIC FEE'
! X.
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED
OCCUPANCY ,"
OCCUPANCY OF BUILDING IS NOT PERMITTED,UNT_ IL BUILDING FINAL IS SIGNED BV BUILDING INSPECTOR'
MICROFILM`
'ELECTRIC
�'A '- + *
RRANGE`F.OR INSPECTION BY'PHONING 252 4505
W
ONE WORKING DAY BEFORE REQUIRED INSPECTION.PLUMBING
PHONING
0 PLEASE GIVE JOB ADDRESS WHEN
t
Z
-.SEE PERMIT FOR. EXPfRATION DATE
' -MECHANICAL
f '
CONST. Tax
1 t
..
WPORTANTI •.Ir
,
' PLEASE READ'REVERSESIDE-BEFORE``=/;
TOTAL
CAL LING_ FOR -FINAL INSPECTION:'" „
,
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION
- APPLICATION & PERMIT
BUILDING- ELECTRICAL, PLUMBING -MECHANICAL
PERMITNUMBER
12413 ^ p A
I G(�, I
BUILDINGb'
AooREss ,I C01S0 �fi rZu.-.tea' Rt,�
- -
OWNERS• _
NAME ('� .' pQ
tm ZM0WhJ' COWS:1 ,PHONE 1 1�' 312-4
QTY, ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION,I
33/
S
CONTRACTORS
NAME '• - '
OUTLETS - SWITCHES -RECEP 10.00/1,00
p�
IF -J22 O'AaW aCeN S'i ', uc No�"36'i/
/�O
' LIGHTING FIXTURES 10.00/1.00 a -
CONTRACTOR
ADD RESS CEh-'TT r"�
APPLIANCES -RESIDENTIAL '4.00 02
PANELS` 10.00 0
//
;?112.1 VKAW"A %FUE-. 'PHONE SA-^, 1:„'
DATE OF APPLICATION
,ARCHITECT
OR• ". _ - u
ENGINEER Vh E_' f -E r LIC. No. RBD 1.T'1 (o
PANELS (OVER 200 AMPI 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH. OR ENG.ti
ADDRESS
SPECIALCIRCUIT 5.00
PERMIT VALI DATION
.,
IEMP. METER OR POLE INS. 20.00 _
- TIP
q�� �•'
APPLICANT - .. -
ADDDRESSDRESS .
n MOTORS '.SEE FEE.SCH. 3
SERVICE CHANGE , 20.00
•
,LICENSED
"
.7/3 7
CONTRACTORS DECLARATION
-
- -
'
1 hereby affirm that-! am licensed under provisions of Chapter 9
(commencing with Section 7000),6f Division 3 of the Business and
Professions Cad and my license is full fogqa and e0'eel
License Class Lic. NumbeJ.�1 6 Z'
ISSUANCE DATE
BLDG. ELECr. PLG. MECH.
Date Contractor
OWNER -BUILDER DECLARATION -
I hereby affirm that I am exempt from the Contractors License
Law for the following reason. (Sec. 7031.5, Business and Professions
Code: Any city or county which requires permit to construct, alter,
BUILDING PERMIT
INFORMATION
MISC.- -' - REFER TO ORD
-
PERMIT ISSUANCE "- - 1000 -
- .
VALUATION
$/FT.
ELEQ CONTR, ,LIC. NO.
-'
ELEC.
TOTAL
improve, demolish, Or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 ofthe
Businees,and Professions Code) or that he is exempt therefrom and
��D
_
PERMIT TO
f
UT/=PE L
CITY. - PLUMBING PERMIT • FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by anyapplicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (5500).):
.. _
! ,/�/�
• 5 ,V q1
,ALTER -DRAIN (EX.) 5.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do tire work, and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
properly who build's or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
merits are not intended or offered for sale. If, however, the building
BACK FLOW PROTECT. DEVICE 4.00 t "
OCC. GROUP
�- 3
RES. UNITS'
/
DRAINS -FLOOR, ROOF, AR EA, COND.' 5.00
-
,I F IXTUR ES - PER TRAP5.00/rj "
SO. FT. FLOOR AREA
TOTAL ACREAGE
"
I GAS - EA. SYSTEM - L I NC. 4'OUTLETS 6,00
ar improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.).
❑ 1, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
,RES IND CON PB Other
1-1❑. ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code. The Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
-
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
-
contracts for such projects with a contractors) licensed pursuant to
the Contractors License Law.
. .
( SEWER -SANITARY -STORM EA200ft11000 O
TRACT NO.
PARCEL NO.
.❑ I am exempt under Sec. ,B.&P.C. for this
reason
I•
-I WATER HEATER W/VENT 6.00
wrier _" Date
I WATER SYSTEM 5.00 -
ACC. DATE
ACC. FILE NO..
WATER TREATING EQUIP. 5.00 .
WORKERS'COMPENSAT1ON DECLARATION
- 1 hereby affirm that I have a certificate ofconsent to self -insure,
or a certificate of Workers' Comperlya�OMs6;Irance, or a certified
copy thereof (Sec. 3800, Lab.C.ss�i
). Ilii
GPA.
Policy Na CompanyOGS KoOrl w201 '
"7
'-
, ZONING
ENG. SITE NO.
,
„
FIRE SPRINK
v❑ N❑
ENERGYT24
Y .N❑
-O Certified is hereby furnished. -''-
❑ Certified copy is,�jled with the city inspection division.
AOPlicant"SRl1✓ Y�po�%^)-
MISC.- - I REFER TO ORD.
" CERTIFICATEOF EXEMPTION FROM WORKERS'
PERMIT ISSUA NCE 10.00 0
FLOOD ZONE
A.L.u.C.
PLG, CONTR. LIC. NO.
PLG.
TOTAL 1/07-0�
- . , COMPENSATION INSURANCE.
(This'scrosco, need But be completed If the permit is for one
Y ❑ N ❑
Y ❑ N ❑
hundred dollars (5100) or less.)
I certify that in the,performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate Ex-
OTY. MECHANICAL PERMIT FEE
-
FEE SUMMARY
BUILDING
ALTER OR ADD TO'MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
to the Workers'Compensation
emption,you should become sa
provisions io the Labor Code, you must forthwith comply with
e, you
such provisions or this permit shall be deemed revoked.
FEE
AIR:HANDLING UNIT (TO 10,000OF.M.). 4.00 ."
AIR HANDLING UNIT(OVER 10MC.EM.) 6.00
SEISMIC FEE
_3'93
CONSTRUCTION LENDING AGENCY"
1 hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) - 5.00
-MICROFILM
the performance of the work for. which this permit is issued (Sec.
3097, Civ.C.).
HEATING UNIT (TO 100,000 B.T.U.) , 8.00
HEATING UNIT (OVER 100,000B.T.U.)9.50
ELECTRIC - �'�
7e4t�
Lender's Name •'-
Lender's Address
I certify that I have read this application and state that the above
information is correct. 1 agree to comply with all city and county
ordinances and state laws relating to building construction, and
'VENTILATION FAN (SINGLE) 4.00 b
PLUMBING
/0 "
'g01LER•CDMP(3 H. P. Dr 100,000 B.T.U.)• 6.00
BOILER -COMP (Over, 100,OODBTU)SEE FEESCH.
MECHANICAL
hereby authorize representatives of this city to enter upon tire.
above-mentioned property for inspection purposes.
MISC. '- REFER TO ORD.
CONST. TAX
-
,�0
(We) agree to save, indemnify and .keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may, in any way accrue against Said City in consequence of the
PERMIT ISSUANCE 10.00 /O
granting of this permit;
if�zxy3¢ew J 3 G 0
O
MECH. CONT. LIC. NO. MECH.
TOTAL dpi
TOTAL
e),?fE3
Signatur o� f Applicant/Cont r Date
��
OFFICE COPY -