16503 • POST THIS CARD NEAR FRONT OF BUILDING. PERMIT NUMBER
CITY OF CUPERTINO 16503
.INSPECTION DIVISION
JOB INSPECTION RECORD
i � � � �� PERMIT EXPIRATION
JOB-ADDRESS_� D2- �•r I� IT# _LOT# '
PERMIT EXPIRES IF WORK
OWNER G(� �/�, CONTRACTOR IS NOT STARTED WITHIN
INSPE TION DATE INSPECTOR INSPEC ON RECORD 180 DAYS OF PERMIT ISSU-
ANCE OR 180 DAYS FROM
NOTE: I
LAST CALLED INSPECTION.
LIFER � � ALL GRADING AND DRAINAGE SHALL BE INSTALLED
TO COMPLY WITH THE APPROVED PLANS AND CITY OF PLHMIT VALIDATION
PR EGUNITE CUPERTINO STANDARDS.
GARAGE SLABS '
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED FWD, L
UNDERGROUND /SLAB - q A
PLUMBING - L N
ELECTRICAL ni ru a ISSUANCE GATE'
MECHANICAL - . . a - BLDG ELECT PLc. MECH
❑ . � ❑ ❑
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT,
WOOD FLOOR INFORMATION
' SIFT,
PLUMBING IFW vnw�rl��
MECHANICAL
ELECTRICAL
PERMIT TO
� ��
FRAMING I k
INSULATION - STORIES TYPE CONST .
OCC.GROUP RES UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF NOTE:NO FINAL INSP.SHALL BE MADE BEFORE sa.Fr FLOOR ARCA TOTAL ACREAGE-
�- DIAPHRAGM. - THE CONSTRUCTION TAX IS PAID
BUILDING USE
ROOF SHEATHING RES
IND[1 ❑N 1:1 ❑ .
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP. -ID
ASSESSORS PARCEL NO
ROUGH SAN.#
PLUMBING ELECT.ENERGY-
TRACTNO. PARCeLNO
TUBS&SHOWER PAN PLUMBING ENERGY
MECHANICAL MECH.ENERGY
ELECTRICAL BUILDING ENERGY ACC DATE ACG.FILENO,
FRAMING ELECT.FINAL TEST
ZONING ENG.SITE NO,
INSULATION PLUMBING
GAS TEST GAS
- FIRE SPRINK ENERGY T-24
MECHANICAL Y ❑ N❑ 'v ❑ N❑
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
EXTERIOR SHEAR ELECTRICAL RELEASE FLOOD ZONE A U C.
,. INTERIOR SHEAR FIRE DEPT. - Y ❑ N❑ 'r ❑ N❑
SHEETROCK GRADE FEE SUMMARY
EXTERIOR LATH BUILDING .
INTERIOR LATH TEMPORARY APPROVALS BUILDING
SCRATCH COAT - ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCYOF BUILDING ISNOTPERMITTED UNTILBUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM •
LU ARRANGE FOR INSPECTION BY PHONING 252-4505,
ELECTRIC
~O� ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
PLEASE GIVE JOB ADDRESS WHEN PHONING:
�l z - 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
+•'bAPPLICATION & PERMIT U1LDING PROJECT IDENTIFICATION gpp '
BDILmNG - PERMIT NUMBER1 6 C 0
AooaEss/O�,cn N \ ��p aL1Ja BUILDING-ELECTRICAL-PLUMBING-MECHANICAL f' I J
3 1
OWNER'S Q 7 1J0 - PLAN CHECK VALIDATION
NAME / QTY. ELECTRIC PERMIT FEE
`4 V ¢t�hNO J.-NK PHONE
CONTRACTOR
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
bio 3a69yd -
uc.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR's
ADDRESS DRESSAPPLIANCES-RESIDENTIAL' 4.00
ADDRESS
3,793lla l a Ce0e 5,0, PHONE 2VJrVS171 IPANELS 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
ADDRESS E"G' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
D
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS
ASMOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
F 02 LICENSED CONTRACTORS DECLARATION - `
¢v I herebyaffirm that 1 am licensed under provisions of Clmpler 9 ISSUANCE DATE
y a e, (Commencing with Section 7000)of Division 3 of the Business and _J BL
' DG. ELECT. PLG. MECH.
Z Hoz Professions C • ^nnsC is in full faryg y')pJ ej[i•
O Llconsc Clu ❑ ❑ O
B - s _ Lia Number ImI
o w Date Contractor\((((,;(!s1
¢ x E d film of CUDeffino BUILDING PERMIT
¢ ¢ w OWNER-BUILDER DECLARATION - INFORMATION
K O A N 1 hereby affirm that I am exempt from the Commctnr'S License MISC.- REFER TO ORD
w 3 u VALUATION SIFT.
H u O a Law for the following reason.(Sec.7031.5,Businessmrd Professions PERMIT ISSUANCE 10.00 O a�
Code:Any city or county which re,dres a permil to Construct alter, Qa000
¢ S¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTA, LIC.NO. ELEC.
in
wO¢ requires the applicant for such permit to file a signed slatanen[that TOTAL PERMIT TO
$ he o he.-.d pursuant to the provisions of the Contractor's License
r z a
Law(Chapter 9(conhmencingwith Section 70001o'Division 3 ofthe
Business and Professions Cod at be is exempt therefrom and OTY. PLUMBING PERMIT FEE ---t... l
ac F $ the basis for the at
ex emItyll ",
nny violation of Section 7031.5 STORIES TYPE CONST .
d$ by any applicant fu operatic s he applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more n fi a hundreos 55001.):
❑ 1,as ow o clip promy employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole coat •ase n,will do the work,and the structure is not
intended or of -red for Sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Cont actor's License Law does 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-
centsare not intended oroffered l'orsale.If,however.the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA.) 200 BUILDING USE
builder will have the burden of proving that he did not build or int- . . . 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 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 lot such projects with it sntractons)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,IT&P.C.Hr this WATER HEATER WIVENT 6.00
reason
Owner Dare WATER SYSTEM 5.00
ACC.GATE ACC.FILE N0,
WORKERS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby aNirm that I have a curtilicate of consent to sell'-insure, ZONING '
or a certificate of Workers'Compensation Insurance,Or a certified ENG.SITE N0.
COPY thereof(Sec.3800,Lab.C.I
Policy NOPy,2a/ad�L Company Zoo, rwep�.retdtz/ynr -
O ❑ Certllled copy lshereby furnished ,(f In( FIRESPRINK ENERGY T-24
Z 2 ��vs,Certified copy is filed qqHit the city inspection division. ,
O A 1b,cant-Cl{rJA _EjmlZ4- MISC.- 'REFER TO ORD. , Y❑ N❑ v'❑ N❑
~ w
LU CERTIFICATE PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
COMS EXEMPTION FROM WORKERS'
W � COMPENSATION INSURANCE PLO.CONTR. LIC.NO. PLG. '
1 O (This sectihin need not be con11111Wd If the permit is for one _ TOTAL Y❑ N❑ V ❑ N❑
2 hundred dollar 15100)or less.)
U O I certify that the performance of the work for which this per. DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued,I sha not employ any person in any manner so as to
U become subject to the orkers'Compensation Laws Cr California.
y Data App' nt ALTER OR ADD TO MECH. 5.00 BUILDING
>- ED NOTICE TO APPLICAN after making this Certificate of Ex-
F 2 emption,you slhould becomes 'vet to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, y must forthwith comply with - FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10DIXICAM.) 6.00 SEISMIC FEE -
I hereby - that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
o
the performance work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). t HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
a
I certify that 1 have rend this application andscuteticabove VENTILATION FAN (SINGLE) .4.00
' information is street I agree tComply with all cityty and county PLUMBING
Ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
/ hereby authorize representatives of this city to enter upon the BOILER-COMP IOver 100,0008TU)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 CONST.TAX
1
may in any way accrue against said City in consequence'of the PERMIT ISSUANCE 10.00
ra hg9 tht er hL MECH.CONT. LIC.NO. MECH.
!!!//�S � TOTAL'
Al'` [,,u1.0 o2=Y-yO TOTAL
Shgnatureo Applicant/ConyRctor Date
OFFICE COPY