17849 POST THIS CARD NEAR FRONT OF BUILDING
PERMIT NUMBER
CITY OF CUPERTINO 17849
INSPECTION DIVISION
JOB INSPECTION RECORD
PERMIT EXPIRATION
JOB ADDRESS / - UNIT# LOT#
—
\ '`` 1 pb n PERMIT EXPIRES IF WORK
OWNER "�� CONTRACTOR C Ly. P�� /�d�� IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION ANCE OR 180 DAYS FROM
NOTE:: LASTCALLED INSPECTION. '
UFER ALL GRADING AND DRAINAGE SHALL BE INSTALLED
PREGUNITE TO COMPLY WITH THE APPROVED PLANS AND CITY OF .M PERMIT VALIDATION
CUPERTINO STANDARDS, PAJ
GARAGE SLABS •
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED MAY 4 19$9 vC�c,.l
UNDERGROUND /SLAB J J V,
PLUMBING
ELECTRICAL Clbl CBpBrtIDD ISSUANCE DATE
MECHANICAL __OG ELECT I PLG. MECH.
El I El 1
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
•' WOOD FLOOR - VALUATION SIFT.
PLUMBING `)
MECHANICAL - / V
_
ELECTRICAL ' - - , ERIN T TU
FRAMING I
S OHIr TYPEC NSTR
INSULATION -
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
• ROOF NOTE:NO FINAL INSP.SHALL BE MADE BEFORE so:PT aooR nREA TOTAL ACREAGE
DIAPHRAGM THE CONSTRUCTION TAX IS PAID
BUILDING USE
ROOF SHEATHING RES - IND CON PB .-Om..
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INS P,: ❑ El 11 El
ASSESSORS PARCEL NO.
ROUGH- SANA
PLUMBING ELECT.ENERGY
TUBS 8 SHOWER PAN PLUMBING ENERGY TRACT NO, PARCEL NO.
MECHANICAL MECH.ENERGY - ACC.DATE . ACC,FILE NO
ELECTRICAL BUILDING ENERGY '
FRAMING ELECT.FINAL TEST . zowmc ENG.SITE No.
INSULATION PLUMBING
GAS TEST. GAS
MECHANICAL
FIRE SPRINK '..ENERGY T-24
❑ v ❑ N❑
'
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING '
Y ❑ N
EXTERIOR SHEAR' - ELECTRICAL RELEASE FLOOD ZONE A.L.0 C.
INTERIOR SHEAR - RE DEPT.
❑
Y❑ N❑ YN❑
FI
SHEETROCK GRADE FEE SUMMARY
_ EXTERIOR LATH BUILDING — —
INTERIOR LATH TEMPORARY APPROVALS BUILDING
SCRATCH COAT ELECTRIC PLAN CHECK - —
GAS FEE-.
NO TAPE OR PLASTER UNTIL'ABOVE HAS BEEN SIGNED OCCUPANCY y , SEISMIC FEE. �
\ OCCUPANCY OF BUILDING IS NOTPERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
1�1 w ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
\ H ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING,
a PLEASE GIVE JOB ADDRESS WHEN;PHONING.
"f z MECHANICAL
— SEE.PERMIT FOR EXPIRATION DATE
IMPORTANT! : CONST.TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL I'
CALLING FOR FINAL INSPECTION.
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
G,N APPLICATION &.PERMIT
ADDRESS
talo P>
` BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 4V 17849
e�lA wlt(C
OWNER'S - - PLAN CHECK VALIDATION
NAME DTV. ELECTRIC PERMIT FEE
41 A PHONE
CONTRACTOR'S
NAME/r , CT UTLETS-SWITCHES-RECEP 10.00/1.00
Q�(AfU LIC.rvo. ,�(�� LIGHTING FIXTURES 10.00/1.00
CONTRACTOR
AooRE q AppLIANCES-RESIDENTIAL 4.00
CAWONE '7 129 PANELS 10.00 DATE OF APPLICATION
ORRcmTECT - - PANELS (OVER 200 AMP) 20.00 .PLAN CHECK FEE C.NO.
ENGINEER ,
/y LIC.No. SIGNS TRANS. 3,00
AARCH.-
DDRESS ENG - SPECIAL.CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 �9
APPLICANTS. MOTORS SEE FEE SCH. (1
ADDRESS ,�,�p_s �f•�
(Y11�PVz SERVICE CHANGE PAID
20.00
Woo LICENSED CONTRACTORS DECLARATION
u u 1 hereby affirm that I am licensed under provisions of Cltnpter 9r MAY
' J ISSUANCE DATE
z w -'(commencing with Section 7000)of Division 3 of the Business and /^� 1
y¢ c �il-IT BLDG. ELECT. PLG. MECH.
r D Z Professions Code,and my license is in full for a I ff - ❑
Z,z H O License C'aass Lin.Number - �s� El ❑, El
H w Dale S �f�-Contractor C'Me Of.Cnperhno
< y 1/ �"' BUILDING PERMIT
M ac w OWNER-BUILDER DECLARATION INFORMATION
W 0 A I- 1 herebyaffirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
,A p VALUATION S/FT.
H LL o a Law for the following reason.(Sec.7071.5,Business Arid Professions PERMIT ISSUANCE 10.00
Code:Any city.,County which requeesapermit to construm alter,
QQ Q Q Improve,demolish,or repair any Structure,prior to its Issuance,also ELEC.CONTR. LIC.NO. ELEC.
DLL requires the applicant for such permit to file a signed statement that TOTAL PERM TO-
w$ he is licensed pursuant to the provisions of the Contractor's License _
HZi
Law(Chapter 9(consmencingwith Section 7000)ot'Division 3 ofthe - 1
¢ Business and Professions Code)or that he is exempt therefrom and GTV. PLUMBING PERMIT FEE l
M =$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a; by any applicantfor a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 occ.GROUP RES.UNITS
their sole compensation,'will Jo the work,and the structure is not
intended or offered for sale(See. 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 SO.FT.FLOOR AREA TOTAL ACREAGE
. himself or through his own employees•provided that such improve. GAS-EA.SYSTEM-I1NC.40UTLETS 6.00
mens are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner. GAS EASYSTEM-OVER 4(EA.) 200 BUILDING USE
builder will have the burden of proving that h - . . .
ime did not build or RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 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:T'he 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 for such projects with a contractons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,BARC.for this WATER HEATER W/VENT 6.00 -
reason
Owner Date WATER SYSTEM 5.00
ACL.DATE ACC.FILE NO.
WORK ERS'COMPFNSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, - ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(S a 3800,Lab.C.I .. d�0�
policy No._WCompaPY M SCA
O ❑ Certified copy Is hereby furnished.W 120 72 FIRE SPRINK ENERGY T-24
Z Z !(�Cerlif d copy is filed with the city mspeclion I isioa. -. MISC.- REFER TO ORD.
O Applicant A Ij.(�I`p5,140 A I Y❑ N❑ I YI'❑ N❑
Hy PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
CC,j CERTIFICATE OF EXEMPTION FROM WORKERS'
LU _ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
1 D (This section need-not he completed if.Ose permit is for one TOTAL Y❑ N❑ Y ❑ N❑
D Z hundred dollars(S 100)or less.)
U O I certify that in the performance of the.work for which this per- TY.GMECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
i BUILDING
Date APPBeam ALTER OR ADD TO MECH. 5.00 -
} In NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Cade, you must forthwith comply with FEE
(J such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.RNL) .4.00 n
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10,000C.RM.).6.00 SEISMIC FEE- L �V
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) - 5.00
the Performanceof the work for which this permit is issued(Sec. MICROFILM
3097,Cw.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name ( HEATING UNIT(OVER 100,000 B.T-.U.)9.50 ELECTRIC
Lender's Address
1 certify that 1 have read this application and state that she above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and slate laws relating to building construction,and
t hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000BTU)SEE FEE SCH. MECHANICAL
abuve-mentioned property for inspection purposes.
' (We) agree do save, i emnify and keep harmless the City of MISC.-' REFER TO ORD.
Cupertino against Babili s,judgments, costs and expenses which' CONST.TAX
may in any wa ac against said City in consequence of the'. PERMIT ISSUANCE 10.00
ranting Of th� MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL 3
Signature of Applicant/Contractor Date
OFFICE COPY