17653 'POST THIS CARD NEAR FRONT OF BUILDING
CITY OF CUPERTINO PERMIT NUMBER
_ , y � . :17653
INSPECTION DIVISION
JOB INSPECTION RECORD
1 }� PERMIT EXPIRATION
JOB ADDRESS C2 �I' C�@"" UNIT# _LOT#
. . PERMIT*EXPIRES IF WORK•
OWNER ,a JACONTRACTOR IS NOT STARTED WITHIN^
INSPECTION DATE I INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION - R ANCE'O180 DAYS FROM
NOTE: LASTCALLED INSPECTION. '
UFER ALL GRADING AND DRAINAGE SHALL BE INSTALLED
TO COMPLYWITH THE APPROVP PL(�N¢AND CITV OF PERMITVALIDATION
PR EGUNITE CUPERTINO STANDARDS. F'1\i 1J G
GARAGE SLABS
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED f
UNDERGROUND /SLAB sw a�
r_�IV� IRUI� �
PLUMBING - Cllr V7 �INIIO i`
ELECTRICAL -- YII ,ISSUANCE DATE
MECHANICAL, , - BLDG .ELECL ' PLG. MEC.
1:1 ❑ .
� ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
- - INFORMATION
WOOD FLOOR
VALUATION S)FT.
PLUMBING
MECHANICAL
ELECTRICAL' �T TO.
FRAMING • uPERn' k
INSULATION - sroRlEs TIFPE CONSTR.
OCC.GROUP HES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
50.FL 110OH AREA TOTAL ACREAGE
' ROOF - NOTE:NO FINAL INSP.SHALL BE MADE BEFORE - -
DIAPHRAGM THE CONSTRUCTION TAX IS PAID
BUILDING USE
ROOF SHEATHING' - . HES IND CON. ,PB Om' ,
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP. ❑
ASSESSORSPARCNO,
ROUGH SAN.#
PLUMBING E ELECT,ENERGY
TRACT NO. PARCEL NO
TUBS&SHOWER PAN PLUMBING ENERGY -
MECHANICAL MECK ENERGY
ACC DATE 'ACC.FILE NO
ELECTRICAL BUILDING ENERGY '
FRAMING ELECT.FINAL TEST •- - zommc ENG.SITE NO.
INSULATION PLUMBING
GAS TEST GAS
EIRE SPRINK ENERGY 124
MECHANICAL - v ❑ N[] v ❑ NQ
COVER NO WORK UNTIL ABOVE^HASrBEEN SIGNED HEATING
FLOODZONE AL.u.c,
EXTERIOR SHEAR ELECTRICAL RELEASE
INTERIOR SHEAR FIRE-DEPT. Y,Q N❑ v ❑ ` N❑'
SHEETROCK - - GRADE FEE SUMMARY
EXTERIOR LATH BUILDING ,
INTERIOR LATH - TEMPORARY APPROVALS Bu1LD�NG
SCRATCH COAT ELECTRIC PLAN CHECK
GAS
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE.
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINALISSIGNEDBY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505,
FELECTRIC
IN- ONE WORKING BEFORE REQUIRED INSPECTION. PLUMBING vd;.
�) O PLEASE GIVE JOB ADDRESS WHEN PHONING.
zI ' MECHANICAL
= SEE PERMIT FOR EXPIRATION DATE -
IMPORTANT!: CONST:TAX
f r1�
' -o
4 PLEASE'READ REVERSE SIDE BEFORE TOTAL p •Q9
CALLING FOR FINAL INSPECTION:
OFFICE COPY
L APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN'ONLY
BUTCOING PROJECT'IDENTIFICATION PERMIT NUMBER
BUILDING -APPLICATION & PERMIT
ADDRESS +'
AOOREaS1 7 nh
22157 �IPQrcI PPI{ .�`l BUILDING—ELECTRICAL— LUMBIN —MECHANICAL l3�• I 1 V5
OWNER'S - µ� Q �7�j PLAN CHECK VALIDATION
NAME II'fd lq{f�J Sr ", Cy Oat/.f QTY. ELECTRIC PERMIT FEE '
996 a¢s�
CONT
NAME
PHONE
UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. ILIGHTING FIXTURES. 10.00/1,00 t
ADDRESS PPLIANCES-RESIDENTIAL 4.00 '
CONTRA aR's
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00 -
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG. - SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
' - ZIP TEMP.METER OR POLE INS. 20.00 y_
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS 22,1 !%7 cleavc&-tw
/ SERVICE CHANGE 20.00
Woo LICENSED CONTRACTORS DECLARATION PAID ISSUANCE
rt u w I hereby affirm that I am licensed under provisions of Chapter 9 - ISSUANCE DATE
1' a (Commencing with Section 7000)of Division 3 of the Busmessand B ELECT. PLG. MECH.
w 4 DG.
F 0 i Professions Code,and my license is in full force and effect. AFK ❑ ❑ a--� ❑
z 0= License Class The.Number .. I/Y�I'
0 H w Dale Contractor - '
¢x s a - - .a BUILDING PERMIT
¢ a a OWNER-BUILDER DECLARATION Cupertino
i?A.v INFORMATION
`< y I hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
w �+ VALUATION $/FT.
FUNj Law for the following or corty,whih c.requi3sa perminess t to construct,
Professions PERMIT ISSUANCE 10.00
� y> � Code:Any city or county which requiresa permit mconstrud,alteq - •
¢ ¢ 4 D Improve,demolish;or repair any Structure,prior to its issouuce,ulm ELEC.CONTR. LIC.NO. ELEC. -
a a D LL requires the applicant for such permit t0 file a signed statement that TOTAL PER IT TO
w m m he is licensed pursuant to the provisions Of the Contractor's License -
>
Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe J/�� Mh
H 4 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE I V� �/I
F a O 'STORIES T ECONSTR.
¢H the basis for the alleged exemption.Any violation otoadvil malty
n ;$ by any applicant fora permit subjects thcapplicant macivilpennity ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(EE00)J: '
�6 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 do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 5.00
Code:The Contractor's License Law does not apply m an owner of G
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP Z .00 ) SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.Provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1.INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- 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 Omer
prove for purpose Of sole.). 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 PARCELNO.
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-OVER 5(EA.) 1.00
contracts for such projects with a contactor(s)licensed pursuant t0
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ Iamexemptunder Sea ' ,B.&P.C.for this WATER HEATER W/VENT 6.00
on
A owner T I WATER SYSTEM 5.00 ACC.DATE ACC.FILE N0.
WORK F.RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 - -
1 hereby affirm that I have u certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING yENG.SITE NO.'
copy thereof(Sec.3800,Lab.C.). -
Policy No. Company
O ❑ Certified copy is hereby furnished FIRESPRINK ENERGY T24
Z Z O Certified copy is filed with rhe city inspection division.p: MISC- REFER TO ORD.
Q Applicant' Y C] N❑ Y ❑ No
v—a CF.RTI FICOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 aDp FLOOD ZONE A.L.U.C.
LU
W COMPENSATION
OMPENSATION INSURANCIi PLG.CONTR. LIC.NO. - PLG. 7 ww
1 0 (This section need not be completed if the permit is for one TOTAL P 64V Y❑. NE] V C) N❑
D Z hundred dollars 1 E 1001 ar less.),
V O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil rs issued,I shall not employ any person in any nhanner so as to
U become subject to the Workers'Compensation Laws of California.
i Data Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE TO APPLICANT: If,after making this Certificate of Es-
Z co ion,you should become subject to the Workers'Compensation 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 10MCF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNITIOVER 10=C.P.M.16.00 SEISMIC FEE
1 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(Ste. HEATING UNIT(TO 100,000 B.T.U.) 8.00 ' MICROFILM
3097,Civ.C.).
Lender's Name - HEATING UNIT(OVER 100,000 B.T.U.)8.50 ELECTRIC'
Lender's Address
1 certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING ( �U
ONinances and state laws refining to building construction,'And BOILER-COMPI3 H.P.Dr 100,0008.T.U.) 6.00 6
hereby authorize'representative, Of this city to entcr�apon the BOILER-COMP(Over 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes. .
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said CAy or cons quence of the PERMIT ISSUANCE 10.00 -
anfi�yo(Ihispermit ,L�/ � � MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL ,Zb DU
Signature of ADPlicant/Colilkctor Date -
OFFICE COPY