11939 POST THIS CARD NEAR FRONT OF BUILDING
PERMIT NUMBER
CITY OF CUPERTINO y3
INSPECTION DIVISION
JOB INSPECTION RECORD
PERMIT EXPIRATION
UNIT# LOT# PERMIT EXPIRES IF WORK
OWNER (CONTRACTOR IS NOT STARTED WITHIN
INSPECTIO DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION
ANCE OR 180 DAYS FROM
LIFER LASTCALLED INSPECTION.
PREGUNITE PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB
PLUMBING
ELECTRICAL ISSUANCE DATE
MECHANICAL BLDG. ELECT. PLG. MECH.
❑ ❑ ❑ ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR VALUATION SIFT.
PLUMBING
MECHANICAL
ELECTRICAL PERMIT TO
FRAMING IQ T'
INSULATION STORIES TYPE CONSTR,
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF ASO,FT,FLOOR AREA TOTAL ACREAGE
DIAPHRAGM
BUILDING USE
HES IND CON Pd Other
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑ ❑ ❑
ROUGH ASSESSORS PARCEL NO,
PLUMBING
GAS TEST l RACT NO, PARCEL NO
MECHANICAL
ELECTRICAL
FINALS DATE INSP. ACC,DATE ACC.FILE NO.
FRAMING SAN #
INSULATION PLUMBING ZONING ENG.SITE NO.
GAS
MECHANICAL FIRE SPHINK ENERGY T 24
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y ❑ N❑ Y ❑ N❑
LATH-INTERIOR ELECTRICAL FLOOD ZONE A.L.U.C.
LATH-EXTERIOR FIRE DEPT. Y❑ N❑ Y ❑ N❑
SHEETROCK GRADE 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 OCCUPANCY SEISMIC FEE l
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINALISSIGNEDBY BUILDING INSPECTOR' MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
IL ONE WORKING DAY BEFORE REQUIRED INSPECTION. "" PLUMBING
O� PLEASE GIVE JOB ADDRESS WHEN PHONING.
/ Z - SEE PERMIT FOR EXPIRATION DATE - MECHANICAL
IMPORTANT! CONST.TAX
PLEASE READ REVERSE SIDE BEFORE
CALLING FOR FINAL INSPECTION. TOTAL
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU [DING PROJECT IDENTIFICATION PERMIT NUMBER
ACIR.U.N APPLICATION & PERMIT
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 11939
/-
OWNERS PLAN CHECK VALIDATION
' NAME QTY. ELECTRIC PERMIT FEE
�- T G ,s(IA-1
PHONE
-4
CONTRACTOR'S
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
R/IDA/ M/l VT AI&C.No. ' S/p b ILIGHTING FIXTURES 10.00/1.00
CONTRACTORS p / �J APPLIANCES-RESIDENTIAL 4.00
ADDRESS�Q l'a 0,1' 60 QL /7/940 Aro\PHHONN EE,JZ6 /y /� PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AM20.00 PLAN CHECK FEE P.C.N0.
OR
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ADDRESS ENG. SPECIALCIRCUIT S.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 IIPZI ,
ADD SSTs MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
J 0/
o o LICENSIiD CONTRACTORS DECLARATION cit ! f g
a v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUA CE DATE I Df)
N w (commencing with Section 7000)of Division 3 of the Business and
Q BLDG. ELECT. PLG. MECH.
H y Professions Code,a I my license is in full fore and effwA. ❑
z o�,- Lluens CI s Lic.Number A.b �C71
4 H w Dote. Contractor �l
a x BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION
o a v INFORMATION
w
g; u y I hereby affirm that I am exempt front the Contractor's License MISC.- REFER TO ORD
F .. o 4 Law for the following reason(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION S/RT.
Code:Any city or county which requires a permit to construct,alter,
2 In¢ < 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
U_
requires the applicant for such permit to file a signed Statement that TOTAL PERMIT T❑
n m he is licensed pursuant to the provisions of the Contractor's License /J
a, Law(Chapter 9Ormimencingwith Section 7000)of Division 3 oftie
i i o Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ H the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; m by any applicant for a permit subjects the applicant toa civil penally
of not more than five hundred dollars(5500).): ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 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,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property Wlm builds or Imp,.,c,thereon,and who does Smelt work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
memsarenotintendedoroffered for sale.I C however,the building GAS-EA.SYSTEM-I1NC.40UTLETS 6.00
Or improvement is sold within one year of completion, the owner GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove For purpose ofsale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB Other
❑ 1,as owner of the property,am exclusively contracting with . .
❑ ❑ El El
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 thcrcon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for Such projects with a contractoos)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
on
Owner Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-insure.
nr a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof fSec.3800,Lab.C.L
Policy No, Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T24
Z Z ❑ Certified copy i filed will, the city inspection division.
F p� Applicant MISC.- REFER TO ORD. YE] N� YE] N[]
it CERTIFICATEOFEXEMPTION I7ROM WORKERS' PERMIT ISSUANCE 10.00 FLOOOZONE AL.U.C.
LU > COMPENSATION INSURANCE. PLG.CONTR. LIC.NO. PLG.
p (This Section need not be completed it the permit is for n, TOTAL V N Y 0 N[]
Z hundred dollrox0lo01 or less.)
U O I certify that in the performance of the work for which this per- QTV. MECHANICAL PERMIT FEE FEE SUMMARY
UL U mit is issued,1 shall not employ any person in an m n so as to
become s yc o the Workers' mpensaY a foram.
U0. Uatc '"YM Applicant 2 I- ALTER OR ADD TO MECH. 5.00 BUILDING G �
} to NOTICE O APPLICANT: If,alter making this ertificate of Ex-
F. Z emption,you should become subject to ire Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER 10,000GEM.) 6.00 SEISMIC FEE efZ7
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of ire work for which this permit is issued(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
. I certify that I have read this application and state that the 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(3H.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, 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 a ainsl ai City n consequence of the
gra ng Of(his y ace n MECH.CONT. CIQ NO. MECH.
-��!/ TOTAL TOTAL s�
7� SignatufenfApplicant/Con[/ or Date
OFFICE COPY