11107 POST THIS CARD NEAR FRONT OF BUILDING
CITY OF CUPERTINO "MIT NUMBER• �\(/,J�D/
INSPECTION DIVISION 11107
JOB INSPECTION dECORD
PERMIT EXPIRATION
JOB AD S UIT LOT#
PERMIT EXPIRES IF WORK
OWNER NTR TOR IS NOT STARTED WITHIN
IMPTCTION DATE INSPECTOR SPE ION RECORD 180DAYS OFPERMIT ISSU-
FOUNDATION ANCE OR 180 DAYS FROM
LAST CALLED INSPECTION.
UFER
PREGUNITE - PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED /
UNDERGROUND /SLAB (//�j/� .
PLUMBING
ELECTRICAL IS uANCE onrE \I
MECHANICAL B}DG. ELECT. PLG. MECH,
❑ ❑ • ❑
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
WINFORMATION
WOOD FLOOR
VALUATION SIFT.
PLUMBING - L6,
MECHANICAL
ELECTRICAL ` P RM TO A
FRAMING 1 Jl
STORIES TYPE CONSTR.
INSULATION
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF SO.FT.FLOOD AREA TOTAL ACREAGE
DIAPHRAGM
BUILDING USE
RES IND CON PB Omer
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑
ROUGH
ASSES,7SPARCEL NO,
PLUMBING
GAS TEST .TRACT NO. PARCEL NO.
MECHANICAL
ACC.DATE ACC.FILE NO,
ELECTRICAL FINALS DATE INSP.
FRAMING _ v SAN # ZONING ENG.SITE NO.
INSULATION - PLUMBING
GAS
FIRE SPRINK ENERGY TPA
MECHANICAL Y ❑ NC] Y ❑ No
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
LATH-INTERIOR ELECTRICAL - FLOODZONE A.L.U.C.
LATH-EXTERIOR FIRE DEPT. Y❑ No Yo N❑
SHEETROCK i GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING 4 '
SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING BJP'
FIREWALLS ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCY OF BUILDING ISNOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY P=252-4505 ELECTRIC
L* � ONE WORKING DAY BEFORE REQPLUMBING
, z PLEASE GIVE JOB ADDRESS WHE— SEE PERMIT FOR EXPIRAMECHANICAL
IMPORTANT! • CONST.TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL J
CALLING FOR FINAL INSPECTION. 7 .
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
,jMUILDI NG PROJECT IDENTIFICATION - PERMIT NUMBER
BUILDING _� APPLICATION & PERMIT 11107
aooRE s
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER' , PLAN CHECK VALIDATION
^• NAME QTY. ELECTRIC PERMIT FEE
IzL CLLAME N£RS DNE 30 cY9
NAME ACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
LIC,No. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR
ADDRESS
PPLIANCES-RESIDENTIAL 4.00
CONTR
PHONE PANELS 10.00 DATE OF APPLICATION
ReHRECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEEP.C.NO.
O
OR
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ADDREOSS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION_
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 S /
Y XJV .
o o LICENSED CONTRACTORS DECLARATION I� s
u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N¢i (commencing with Section 7000)of Division 3 of the Business and G. ELECT, pg1 ECH.
F m o' Professions Code,and my license is in full force and effect ,^�ryly� V}uWt' ❑
Z, o u,- License Class Lic.Number
4 T H w Date Contractor
< , s BUILDING PERMIT
5 at w u OWNER-BUILDER DECLARATION INFORMATION
P.
;LL m I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION $/FT.
Seo¢ Law forthe followingreasoo.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
SwCode:Any city or count y which requires a perm it to const ruct alter,
IC r 4 O Improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
y E o u requires the applicant for Such permit to file a signed statement that TOTAL PEflM T TO
P,$ he is licensed pursuant to the provisions of the Contractor's License
r z r
Law(Chapter 9(commencingwith Section 7000)of Division 3 oftlhe
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
51 o the basis for the alleged exemption.Any violation of Section 7031.5 _ STORIES TYPE CONSTR.
n ;m by any applicant for apermit subjects the applicant tuacivil
penalty ALTER-DRAIN -WATER (EA.) 5.00
of n t more than five hundred dollars($500).):
I as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
it it ole compensation,will do the work,and the structure is not DCC.GROUP RES.UNITS
in ended or offered for sale(Sec. 7044, Business end Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law docs not apply to an owner of
• property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedl'or sale.If,however,lite building GAS-EAI SYSTEM-1INC.4 OUTLETS 6.00
or improvement is sold within one year of Completio),the nwner- 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 sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,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 ASSESSO PARCEL NO.
and Professions Code:The Contractor's License Law docs 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 SEWER-SANITARY-STORM EA.200tt/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exemptunde Sec. ,BAP.C.for this /VENT 6.00
reason
OwnerDate T WATER SYSTEM 5.00 ACC,DATE ACC.FILE NO.
�KF-RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE N0,
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T24
Z 2 ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD.
Q Applicant Y EJ N❑ Y ❑ N❑
� N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
LU >_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d O (This Section need not he completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
+ Z) Z hundred dollars IS 100)or lesS.) '
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued.1 shall not employ any person in any manner So as to
O income subject to the Workers'Compensation Laws of California.
0 y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT'. If,after milking this Certificate of Ex-
F 2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10p00C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which(his permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(T0 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I have read this application and statethat tine above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP I3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, 'nit fy and keep harmless the City of MISC.- REFER TO ORD.
Cupertin m I' ies,j gments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may i any wa c ,ag it
Said City in nseyucn<e of the
gran ngo th' MECH.CONT. LIC.NO. MECH,
TOTAL TOTAL
Sigrakure2A,l.IicagtjComraclor Date'
OFFICE COPY