8967 — 1
POST THIS CARD NEAR FRONT OF BUILDING RMIT NUMBER
CIT`I�F . CUPERTIN
�+ INSPECTION DIVISION
1•>, JOB INSPECTION RECORD
PERMIT EXPIRATION
JOB AD ESS UN T#
F - PERMIT EXPIRES IF WORK
owNER c NTRACTOR IS'NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RCORD 180 DAYS OF PERMIT,ISSU.•.
FOUNDATION - ANC. ORF 180 DAYS FROM
UFER
- LAST CALLED INSPECTION.
BREGUNITE
PERMIT VALIDATION
- � � '
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED rn^
UNDERGROUND /SLAB �O �l�/
PLUMBING
ELECTRICAL
IS4SUAN DATE
ELECT.
.MECHANICAL a ELECT. Lc. MECR.
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING P RMIT
INFORMATION
WOOD FLOOR
PLUMBING VALUATION
� .
MECHANICAL ' Al
PERMIT T '
ELECTRICAL `
FRAMING -
INSULATION - - TORETYPE C< sTR. '
OCC.GROUP RES.UNITS
PLACE NOS F
UB LOOR UNTIL ABOVE HAS BEEN SIGNED
•� ROOF - SO.FT.FLOOR AREA TOTALACREAGE
DIAPHRAGM
BUILDING USE
_ RES IND C PB O,nn, ,
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑ �`
ROUGH ASSESSOR CEL NO.
'
PLUMBING _ 1
GAS TEST TRACT NO. PARCEL NO.
MECHANICAL
ACC.DATE ACO.FILE NO.
ELECTRICAL, FINALS DATE INSP.
FRAMING _ — (� SAN # I
4 ZONING ENG.SITE NO.
INSULATION PLUMBING .6 - t
GAS
MED ICAL , '•' FIRE SPRINK ENERGY T14
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HE IN "� "�
LATH—INTERIOR E CTR CAL FLOOD ZONE A.L.0 C.
LATH—EXTERIOR FI E DEPT. Y❑ N❑ Y❑ IN E]
SHEETROCK G DE -FEE SUMMARY
SHEAR INTERIOR BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING
FIREWALLS ELECTRIC PLAN CHECK
GAS - FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED JOCCUPANCY SEISMIC FEE '
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED13Y BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC '
F ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING —�
` •c O� PLEASE GIVE JOB ADDRESS WHEN PHONING.
Z MECHANICAL
• — SEE PERMIT FOR EXPIRATION DATE —
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
BU I LOING PROJECT I DENTI FICA _ PERMITNUMBER
BDIEo NG APPLICATION & PE
ADDgE
ia2s,k� ILDING-ELECTRICAL-PLUMBING-MECHANICAL 8967
OWNER'S
NA E PLAN CHECK VALIDATION
,• ///n//J )'1 1*5-7' 'yj QTY. ELECTRIC PERMIT FEE
l.� 2-
PRONE..) / /�/ I ��q./
CONTRACTOR's UTLETS-SWITCHES-RECEP 10.00/1.00
Ac.NO. LIGHTING FIXTURES 10.00/1,00
nooeess TDRIS'I _ t APPLIANCES-RESIDENTIAL 4.00
/+ PRONE PANELS 10.00 DATE OF APPLICATION
OARCHITECT PANELS (OVER 200 AMP) 20,60 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.NO. SIGNS TRANS. 3.00
sooe[ss ENG' SPECIAL CIRCUIT 5.00 PMDATION
ZIP TEMP.METER OR POLE INS. . 20.00
sooREssTa MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 ,,, �)�
,02
0o LICENSED CONT TORS DECLARATION TEMP.POLE 30,00 CitygEl
a v u I hereby affirm thut I um licensed under provisions of Chapter 9 V LIISSJ%A NICE DATE
w< w (commencing with Section 7000)of Division 3 of the Business and B ELECT. PLG. MECH.
w2 Professions Code,and my license is in Divi force and effect. ❑ El LEI G 0 w W License Class Lic.Number
Date Contractor
Q y J
BUILDING PERMIT
o n O OWNER-BUILDER DECLARATION11. INFORMATION
X g h I hereby affirm that I am exempt from the Contractor's License MISE.- REFER TO ORD
u O< Law for the following reason.(Sec.7031.5,Business and Professions VALUATION
$/FT.
L - u, PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,otter,
22 Q 2O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
y y O u requires the applicant for such permit to file a signed stmement that TOTAL PERMIT TO
w m m he is licensed pursuant to the provisions of the Contractor's License
rz >
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe �r(/'Tr �/Jyp�UVLs
1 i a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
r$ the basis for the alleged exemption.Any violation at Section 7031.5 STORIES TYPE CONSTR.
ag - by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner f'the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
their sale 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 to.not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.06 1pd4�0- SG.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such I...I-e-
Rentsarenotintended or offered for sale.l f,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of Completion,the owner. GAS-Eq.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
pfor purpose ofsale.). RES INO CON PB Other
I,as owner ol'the property,Rn exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 11 RES
El El 1:1lie sed 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 contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRALTNO. PARCEL NO.
❑ lam exempt under Sec.�_,B.&P.C.for th is WATER HEATER W/VENT 6.00
I reason /p
Owner Date WATER SYSTEM - 5.00
ACC.DATE ACO.FILE NO.
WORKERS'COMPENSATION 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,oro Certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
p O Applicant Y F] N� V ❑ N[]
cr T CERTIFICATE OI'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 Q sv FLOOD ZONE A.L.u.c.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. �(^/Q-p
1 N E Y C] NCDO I'fhis section need not be completed if the permit is for one TOTAL J Y
Z hundred dollars IS 100)Or less
U O 1 certify that in the performance of the work for which this per, QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,1 shall not employ any person in any mon ter so as to
U become subject to the Workers'Compensation Laws of California.
Date Applicant BUILDING e"teS-0
CL ALTER OR ADD TO MECH. 5.00 ! / •�
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? emption,you should become iubject 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 10=CF.M) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOXMC.EM.) 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 this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) .8.00
Lender's Name H EATI NG UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and ,are ,
that[he above VENTILATION FAN (SINGLE) 4.00 information is correct. I agree to comply with all city and county PLUMBING V
ordinances and state laws relating to building construction, and BOILER-713(H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upo0 the BOI LER-COMP(Over 100,000 BTU)SEE FEE SCH. 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 PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
grantin f this permit. - MECH.CONT. LIQ.N0. MOCH. OC7
TOTAL ��
Ign ure of Applin onlmctor / Da[
OFFICE COPY