12354 POST THIS CARD NEAR FRONT OF BUILDING
PERMIT NUMBER
CITY OF CUPERTINO 1.2354
INSPECTION DIVISION
JOB INSPECTION RECORD
I O _1 1 / PERMIT EXPIRATION
JOB ADDRESS �• 111 1 IT tt' LOT#
PERMIT EXPIRES IF WORK
OWNER CONTRACTOR IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION ANCE OR 180 DAYS FROM
UFER
LASTCALLED INSPECT If
N.
PREGUNITE
PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED r _,
UNDERGROUND /SLAB
PLUMBING '
ELECTRICAL '
ISSUANCE DATE
MECHANICAL BLO ELECT. PLG. MECEL
❑ ❑ ❑
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
WOOD FLOOR INFORMATION
PLUMBING VALUA14ON SIFT.
MECHANICAL w+
ELECTRICAL - ERMIr To
FRAMING ..
INSULATION ST TYPE CONSTR.
CC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF SO.FT.FLOOR AREA TOTAL ACREAGE
DIAPHRAGM
BUILDING USE
HES IND CON PB 011-
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED El El El ❑ ❑
ROUGH
ASSESSORS PARCEL NO.
-
PLUMBING
GAS TEST TRACT NO. PARCEL NO.
MECHANICAL
ELECTRICALFINALS DATE INSP. ACC.DATE ACC.FILE NO.
FRAMING SAN #
INSULATION PLUMBING ZONING ENG.SITE NO.
GAS
MECHANICAL FIRE SPRINK ENERGY T.2C '
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y ❑ N❑ Y ❑ N❑
LATH—INTERIOR ELECTRICALFL000 zoNE A-L.U.C,
LATH—EXTERIOR FIRE DEPT. v❑ 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
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
LU ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
ONE WORKING DAY BEFORE REQUIRED INSPECTION; PLUMBING
Z PLEASE GIVE JOB ADDRESS WHEN PHONING.
- SEE PERMIT FOR EXPIRATION DATE - ' MECHANICAL
IMPORTANT! CONST.TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICECOPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT I IDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER
AUDRESSs
164IL4 E. Es}a4-es D7-1 Ve BUILDING- ELECTRICAL-PLUMBING-MECHANICAL 12354
ovs,noS �1 PLAN CHECK VALIDATION
NAME x'115—as I-a aq4 QTY'
TY ELECTRIC PERMIT FEE
Mgrk S�ht�le� �dSb�E44b-451a
NAMERAcroRs UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
A OORESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.O.NO.
ENGINEER
i LIC.NO, SIGNS TRANS. 3.00
ADDRESS ERG. PERM CIRCUIT 5.00 S PERMIT VALIDATION
-ZIP EMP.METER OR POLE INS. 20.00.
Avvucnrvrs
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 P�D
0¢ i
Foo LICENSED CONTRACTORS DECLARATION
¢U u 1 hereby affirm that 1 am licensed under provisions of Chapter 9 IS A C
(commencing with Section 7000)of Division 3 of the Business and
r w Professions Code,and my license is in full force and effect.
i 0 EL MECH.
z 0 m - License Class Lie.Number
9 y Date Contractor 'n
¢ ¢w a OWNER-BUILDER DECLARATION I IN PERMIT
w ; LL y I hereby affirm that 1 am exempt from the Contractor's License RD
MISC.— REFER INFORMATION
r u o vo Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 r/lam VALUATION S/FT.
Code:Amycity orcounty which requires a permit to construct,alteq Q
aa improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
K m, requires the applicant for such permit to file a signed statement that TOTAL }��-
w he is licensed pursuant to the provisions of the Contractor's License MOTTO
H z Q Law(Chapter 9(commencingwith Section 7000)of Dlvision3ofthe
2 O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H S the basis for the alleged exemption,Any violation of Section 7031.5 „ STORIE TYPE CONSTR.
n ; _ by any applicant five hundred t subjects
S500).he licam loacivil penalty ' ALTER-DRAIN VENT-WATER (EA.) 5.00
of not more than five hundred dollars(my em): If
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECTDEVICE 4.00
their sole .le compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
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 who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve GAS-EA.SYSTEM-1 6,00
ments are not intended or offered for sale.If,however,the building
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 of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(See. 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 contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SAN ITARV-STORM EA.200ft/10.00 TRACT NO. PARCEL NO,
❑ ldmexemp under Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00
roTOJ
'X OeaswnDate WATER SYSTEM 5.00
ACG DATE ACC.FILE NO.
CE MPE. SATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.CJ,
Policy No. Company
O ❑ Certified copy Is hereby furnished.
Z Z ❑ Certified copy is filed with the city inspection division. FIRE SPRINK ENERGY T 24
O Applicant MISC.- REFER TO ORD. Y [3 IN Y [:] N�
CCN CE RTI FICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOOZONE A.L.U.C.
LOU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d O (This section need not be completed if the permit is for one TOTAL Y❑ N[] Y N�
0 Z hundred dollars IS 100)or lan.)
U O I certify that in the performance of the work for which this per- OT,r MECHANICAL PERMIT FEE FEE SUMMARY
IL 1- mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
a Date Applicant - 'BUILDING 9 Sa
} N NOTICE TO APPLICANT: If,alter making this Certificate of Ex ALTER OR ADD TO MECH. 53
00
.
F. Z emption,you should become subject to the Workers'Compensatiun - 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 10AMCF.M.) 4,00 FEE r2�
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE SCJ
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 500 --
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
Lender's Address HEATI NG UN IT(OV ER 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 v
information is correct. I agree to Comply with all city and county PLUMBING
ordinances and state laws relating to building construction. and BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP(Over 100,000 BTUI SEE FEE SCH. MECHANICAL
(We)r agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any a e an it said City in consequence of the PERMIT ISSUANCE .10.00
oft i MECH.CONT. LIG NO. MECH. /♦)
/ TOTAL TOTAL
7� Sig tore p t o mci . DL
! 'A
OFFICE COPY