19544 POST THIS CARD NEAR FRONT OF BUILDING ruaM rNo.
r 19544
CITY OF CUPERTINO
INSPECTION DIVISION- JOB INSPECTION RECORD �)
JOB ADDRESS O -I 3 O S D be �-L Z✓ B `UFIIT# 'LOT# - CA RY CONTROL x
OWNER W'Vl- Gp CONTRACTOR �:. BUILDING PERMIT INFO
'.INSPECTION, DATE INSPECTOR INSPECTION RECORD ❑ ❑ O
FOUNDATION/PIERS NOTE ALL GRADING AND DRAINAGE
UFER GROUND SHALL BE INSTALLED TO COMPLY MTTH JOB DESCRIPTION
PAD SETBACK-CERT THE APPROVED PLANS AND CITY OF
GARAGESLABS PREGUNITE CUPERTINO STANDARDS. f
POIIR No CONCRETE LENTIL ABOVE HAS BEEN SIGNED �c1.I
UNDERGROUND SLAB INSPECTION DATE INSPECTOR
PLUMBING
ELECTRICAL
MECHANICAL
DO NOT-POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED
WOOD FLOOR
PLUMBING - ,
MECHANICAL -
ELECTRICAL -
FRAMING/VEN15 CLEAR
INSULATION -
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED DATE
ROUGH
PLUMBING
TU13S&SHOWER PAN
MECHANICAL
ELECTRICAL ACUZZI 13OND '
FRAMING STAIRS
INSULATION/VENTILATION
GMERG.EGRESS '
SEWER WATER
(CO.VER1N01{NORK UNTIGABO If HAS BEEN SIGNED
EXTEMORSHEAR HOLDDOWN
INTERIOR SHEAR/HOLD DOWN .
SHEETROCK/SHEETROCK SHEAR
EXTERIOR LATH/W-SCREEN
SHOWER LATH
SCRATCH COAT
NO TAPE OR PLASTER UNTIL ADO HAS BEEN SIGNED
NOTE:NO FINAL INSPECTION SHALL BE MADE BEFORE THE CONSTRUCTION TAX IS PAID
FINALS DATE IINSPECTOR
SAN.#
ELECT.ENERGY
PLUMBING ENERGY
MECH.ENERGY
BUILDING ENERGY
ELECT.FINAL TEST
PLUMBING
GAS TEST
MECHANICAL
HEATING
ELECTRICAL RELEASE
FI RBDEPT.
GRADE
OCCUPANCY -
TEMPORARYAPPROVALS
ELECTRIC -
GAS
BUILDING
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL - ISSUANCE DATE
BUILDING,FINAL IS SIGNED BY BUILDING INSPECTOR - MD
ARRANGE FOR INSPECTION BY PHONING 252-4505 BETWEEN
12:30 PM AND 4:30 PM MONDAY THROUGH FRIDAY,24 HOURS i0l 3 1 y�
BEFORE REQUIRED INSPECTION. JOB ADDRESS AND
PERMIT #ARE NEEDED WHEN PHONING. Clt' ^II^""rfino
IMPORTANT!
PLEASE READ REVERSE SIDE BEFORE CALLING FOR FINAL INSPECTION ISSUEDBY:__�I
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Build
Bin ProMat Identification PERIdITNO.
ulldi tlreBu
"i :. s . �� �2ic� : 19544
weer. ams: PhAPPLICATIONSUBMITrAr one:
U u CITY OF CUPERTINO-BUILDING DIVISION qA'
c°""a `°''"e`NIB Lic.No: APPLICATION / PERMIT4 — 2-
Z3
BUILDING-ELECTRICA4PLUMBINGMECHAMCAL CA RY CONTROL# .
Architect glneer. Lk.No:
QTY
ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addeeac �P
Nl FERMITISSUANCE _ ❑ O ❑ m
LICENSED CONTR under DECLARATION Lam}
]hereby afflmnthatlam licensed underprovlslone of Chapter9(mmmmc- APPLIANCESRESIDENTIAL JOB DESCRIPTION
mgwith Sccd..7000)o(Dlvision3 ofthe Eusimasand Professions Code,and my
license is In ruR farce and effect. - PANELS IN IQ 2DO AMPS po
License Clam Lic.p� `c— L
Date I12r1T�Cor
ARCHITECT'S DECLARATION 401-1000 AMT'S' .
O CZO Iundroused my plamshallbe used as pubBeremrds. OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
Z, Licensed Pro(essioml SIGNSELEC ICAL
-�6 OWNER-BUILDER DECLARATION
ZF, � Ihereby affirm that lam exempt fromthe Centrad.e.License Law fee the SPECIAL CIRCNT/MIST -
O 99 F- following recon.(Section 7011.5,Business and Professions Code:Any city or
p� cmntywhkhmquiresaper tbmwhud,ilter,bnpmw,demolath,orrepair TFMP.METER ORPOLE INST.
qa
ny structure pew to its issuance,also requires the applicant for such permit to
K1 O (ne a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES I -
Wb p, Contractor's Lkerse Gw(Chapter9(mmmencingwith Sedhm7000)°r Divi- !I
�O sion3o(the Buslneeeand Profems mCade)orthatheisommpttherefromand SWN4MiNGPOOLELECTAIC LUATIO
,;2
the basis for the il4ged exemption. Any violation o(Sectbn out by any OUILETSSW[TCHFSH%TURES --
m t`C appliant(ora permit ubjectatheappgcanttoactvil pemlty olnot ration
flue hundred dollars($500). NEW RESIDEN'ITAL ELECTR
�n ❑I,as owner or the property,or my employees with wages as their sole SQ.FL STORl[S TYPE CONSTRUCTION
compensation;w111dothe wwk,andtbestucNrebnoHe ded or oiferetl for ^w 1p
q sale(Sec.7044,Buslmae and Profembm Code:The Contract
Wmrrte Law VA �pV
F $ does not apply to an owner orproperty who builds or improv.thereon,and OCC.GROUT' RFS.UNITS
whodoessurh workhimsel(orthrough hisownemPloyeea'P
pided tbatuch
Improvements are not Intended muffered forsale.If,howevei,tbebuiWing Winger TOTAL:
Improvement ls sold within oneyearo(complefin_the owner-bullderwlll have '
t ,no of Proving
he did not build or Improve for purpea Isabel. QTY. PLUMBING PERMIT FEE FLODD7DNE APN
L,f 4'as owner,of the property,em exduslvely contracting
with licensed pEgMl'C ISSUANCE
contra...toe mtro.the project(Sec9044,Business and ProirstaL Code:
The Cont.ctore License Law does not apply to an owner of property who ALTER-DRAIN or Improves thereon;and who contracts for such p(ojects with a DRAIN&VENT-WATER(EA)
co,Il[Tador(s)homsed pursuant to the Commentre License Law, FEE SUMMARY
LJ I am exempt under Sec B&P C for that reason BACK FLOW PROTECT.DEVICE
Owner Date DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION RECEIPT#
it l hereby eHlrm that I have a mrti0cate or consent to self-inure,or a FIX1UI F PER TRAP SCITOOL TAX Y N_
cfrtift<ate°f Worker,'C.mparanon lruunncewacettitied mpythere°f(Sec. - RECI]PT#
S E
3800,Lab C.), GAA.SYSTEM-]INC.4 OUTLETS PARK FEE Y N
Poll It
Com any GAS-FA.SYSTEM-OVER4(FA) BUILDING RECEIPT
FEES
[P Certified copy is heubyth the ed.city
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
'❑Certlfled copy at filed with the tlty Inepectl.n division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(Thissectlon need not becompleted ifthepermit is(oranehundred dollars SEWER-SANITARY-STORM EA,200FT. Date Recei t#
($100)bify that
WATER HEATH,W/VENT/ELECTR ENERGY FEE Y N
]certify thatlnthe person nce I-an thewwk.asto hthis
ce,sub is issued, —
I shall not employ any person In any manner so m to become subject to the WATER SYSTEM/TREATING
Worlicant omponensatlfawn or Gll(ornb.Data PAID
0 Z Applicant" Date
Z 0 NOTICE TO APPLICANT:ILafter rtuking this Certlieate of Exemption,you NEW RESIDENTIAL FILMS. SQ,FT. Recei t#
should become subject to the Workers'Compeneatlon previsions of the Labor TOTAL:
fn Code,you moat forthwith mmplywithauch provialomorthat permit shallbe
W5 deamedrevoked. BUILDING FE
C p CONSTRUCTION LENDING AGENCY - SEISMIC FEE '
I hereby affirm that there ls a construction lending agency forthe perform SEISMIC
FEE
n O ance of the work for which this permit is issued(Sce.3097,Civ.C.) TOTAL:
02 Lenders Name PLUMBING FEE
LL H Lendxrs Addmsa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE UQ
O W I.Airythatl h.ve..dthatapplialionandstatethattheaboveinfornuti°n
IL lsmrred.Iagree to comply withal)city and county ordinances and state laws PERMTTISSUANCE LOU, FEES PAID:
Nrelating to building mmtrudion,and hereby authorize representatives of this //,, -
Z city to enter upon the abovementloned property for inspection purposes. ALTER OR ADD TO MECH. 9s (1 v
_ (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receip[#
agalnstllabWmenh
ties,7,dg ,ma
xtsandexpemeswhich neyln anywayacue - AIR HANDLING UNIT(TO 10,ODO CPM) SUBTOTAL-
11
agalmt said City in mry
muence of the grant lnkof this permit.
C IIja�lcltj AIR HANDLING UNIT(OVER IO,000 CFM) CONSTRUCTION TAX
Sigmturc Applicant/Cont actor Mid
,t EXHAUSTHOOD(W/DUCT) - CONSTRUCTION TAX PAID:
HAZARD US MATERIALS DISCLOSURE
Will the appllcam orfuture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Seam 25532(a)i HEATING UNIT(OVER 100,000 BTU)
❑Yea No TOTAL: ,Q
Will theappliarilo (uturebuildtngoccvpant use equipment orcievices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air }E��pp�
Quality Management Dl tj iid7 BOILER-COMP QHPOR 100,000 BTU) PAJ0
4 az
Yea ryJ No
have mad the ha .us materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU) ��� 3 I�y�
the California Health&Safety Code,Sections 25505,25533 and 25534. 1
•� underetand that ifthe building does not currently havea temuLthatltlsmy NEW RMDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requlrceent which must be met a, t ,.F)
prior to issuance of a Certificate of Occupancy. CI`•/ nl �.UFIAI I^II�
41L*IA clNo.--- I1 ,I%-
,weerorVthoriudagent C to I ISSUEDBY: 0
TOTAL: �I.Uy
OFFICE COPY