11965 POST THIS CARD NEAR FRONT OF BUILDING
PERMIT NUMBER
041 CITY OF CUPERTINO 11965
INSPECTION DIVISION
JOB INSPECTION RECORD
I PERMIT EXPIRATION
JOB ADDR ESS UNIT LOT#
PERMIT EXPIRES IF WORK
OWNER. CONTR CTo d__�l IS NOT STARTED-WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATIOtILS - ANCE OR 180 DAYS FROM
LIFER ' LAST CALLED INSPECTION.
PR EGUNITE PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED t f ti
UNDERGROUND /SLAB
PLUMBING
ELECTRICAL ISSUANCE DATE
BLDG. ELECT. PLG. MECR.
MECHANICAL
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR - 'VALUATION $/FT.
PLUMBING
j MECHANICAL '
ELECTRICAL PERMIT To
FRAMING
STO IES TYPE CONSTR.
INSULATION
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL,ABOVE HAS BEEN SIGNED
• ROOF 50.FT.FLOOR AREP .TOTAL ACREAGE
DIAPHRAGM ,
BUILDING USE
• RES IND CON PB Ober
APPLYAO ROOFING UNTIL ABOVE HAS BEEN SIGNED El C-1 1:10
ASSESSORS PARCEL NO.
ROUGH
PLUMBING
TRACT NO. PARCEL NO.
GAS TEST
MECHANICAL
ELECTRICAL. ' FINALS DATE INSP. ACC.DATE ACC.FILE NO.
FRAMING 4� \q, •Y�I> SAN #
ZONING ENG.SITE NO.
INSULATION. z, PLUMBING
GAS
FIRE SPRINK ENERGY T 24
MECHANICAL
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y ❑ N E Y• .L "❑
LATH—INTERIOR ELECTRICAL PLooO zorvE A.L.U:C.
LATH-EXTERIOR 1-X13--� FIRE DEPT. YE] N❑ Y0,
SHEETROCK GRADE - FEE SUMMARY '
SHEAR INTERIOR - BUILDING BUILDING
SHEAR EXTERIOR - TEMPORARY APPROVALS'
FIREWALLS ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED JOCCUPANCY I SEISMIC FEE
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252 4505, ELECTRIC
� ONE WORKING DAY BEFORE REQUIRED INSPECTION.'. PLUMBING
t z PLEASE'GIVE JOB ADDRESS WHEN PHONING.
SEE PERMIT FOR EXPIRATION DATE - MECHANICAL
IMPORTANT!
CONST.TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY '
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BGILDIN APPLICATION & PERMIT
ADDRESS
Cl l 7 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S / 425&.3&
vv PL AN CHECK VALIDATION
•
NAM PH rom ELECTRIC PERMIT FEE
PHD
CONTRACTOR s. UTLETS-SWITCHES-RECEP 10.00/1.00
NA E LIC. GHTING FIXTURES 10.00/1.00CONTRACTORS PLIANCES-RESIDENTIAL 4.00ADDRESS
r NONELS 10.00 DATE OF APPLICATION
NELS (OVER 200 AMP) 20,00 ENGINEER GNS TRANS. 3.00LIC.ARCH.OR ENG. ' 5.00PERMIT VALIDATION
PECIALCIRCUIT EMP.METER OR POLE INS. 20.00AP a ANTS OTORS SEE FEE SCH.ADDRESS
ERVICE CHANGE 20.00
wo o LICENSED CONTRACTORS DECLARATION
<is w I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
Q (commencing with Section 7000)of Division 3 of the Business
and BLDG. ELECT. PLG. MECH.
❑ ❑�i Professions Code, y license is in full Corezo License Class LLc Numhe0 Contracla 12 f J BUILDING PERMIT
Ic iL 0w p O NER-BUILDER D- INFORMATION
w u w I hereby affirm that I am exempt from the Contractor's License
MISC.-
REFER TO ORD VALUATION 5/Fr.
u o a Law for the following reason.(Sec.7031.5,Business and Professions pERM1T ISSUANCE 10.00 Q
t ,�m I Code:Any city or county which requires permit to construct,alter,
C Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.LDNTR, LIC.NO. ELEC. �1 w
O u requires the applicant for such permit to file a signed Statement that TOTAL �-E/ PERMIT TO
E
$ he is licensed pursuant to the provisions of the Contractor's License
Hii Law(Chapter 9(commencing with Section 7000)ofDivision3ofthe
3 4 o
STORIES TYPE CONSTR.
Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
Ix 1-$ the basis for the alleged exemption.Any violation of Section 7031.5
s ; by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).1.
❑ 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,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 F IXTUR ES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that Such improve- GAS-EA.SYSTEM-i INCA OUTLETS 6.00
meats are not intended or offered for sale.11,however,the building
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 Pe Other
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. ..30.00 ❑ ❑ ❑ ❑ ❑
❑ I,as owner of the properly,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 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 contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 - TRACT NO. PARCEL NO.
❑ l am exempt under Sec,.,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION D17CLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a cerlIIIa e f Workers'aensatio In urance ori a certified
copy Ih o
Policy P'
O ❑ Certifiedc here f e2 FIRE SPRINK ENERGY T-24
Z Z XCertif
to
d i 'i Inspection division. MISC.- REFER TO ORD. Y❑ N� y ❑ NF
Applicant
I"' vO-i PERMIT ISSUANCE 10.00 FLOODZOI'vo
K - CE 1171CATI:OF EXEMPTION FROM WORKERS'
J COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
LU -LU O TOTAL Y
(This section need not be completed if the permit is for one
� Z hundred dollars($100)or less,) FEE SUMMARY
V O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE
LL mil is issued,1 shall not employ any person in any manner so as to �S�
O or become ubject to the Workers''Compensation Laws of California. BUILDING 3
Date Applicant ALTER OR ADD TO MECH. 5.00
} tp NOTICE TO APPLICANT: If,after making this Certificate of Ex- 5.00 PLAN CHECK
Z emption,you should become subject to the Workers'Compensation APPLIANCE
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=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.RM.) 6.00 SEISMIC FEE LJO
1 hereby fit that there is I construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 MICROFILM
the performance of the wo ; which this permit is issued(Sec. HEATING UNIT IT 100,000 B.T.U.)' 8.00
3097,Civ.0 1 -1
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC p�Q
Lender's Address_
I certify thatihave r,adthis a.plication and state that the above I IVENTILATION FAN (SINGLE) 4.00 PLUMBING
information is correct.I agree to comply with all city and county BOILER-OOMP(3 H.P.Dr 100,000 B.T.U.) 6.00
ordinances-and state laws relating to building construction, and
hereby authorize representatives Of this city to enter upon the BOILER-COMP(Over IGD,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purpous.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. CONST.TAX
Cupertino against Babilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00
may in any way accrue against said City in consequence of the
granting of this permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL 39�
Signature of Applicant/Contractor Date
OFFICE COPY