11644 f POST THIS CARD NEAR FRONT OF BUILDING /
I'ER%IIT NUMBER
CITY OF CUPERTINO 11644
INSPECTION DIVISION
I rq OB INSPECTION RECORD
)M" PERMIT EXPIRATION
S JOBADDRF,S, UNIT# LOT# PERMIT EXPIRES IF WORK
I
OWNER 'G�' CONTRACTOR IS NOT STARTED WITHIN
INSPECTION PATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
ANCE. ANCE OR 180 DAYS IF,ROM
UFBR
LAST CALLED INSPECTION
PREGUNITE _ PERMIT VAUDATIO)
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED I\� I\
UNDERGROUND /SLAB /
PLUMBING - - -
ELECTRICAL _ ISSUANCE DATE
MECHANICAL BLDG ELECT. PLG. MECH.
❑� El ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
_ INFORMATION
WOOD FLOOR
PLUMBING VALUATION S/FT.
' � _ •
MECHANICAL
ELECTRICAL - PERMIT TO
' FRAMING '
INSULATION
I � � ® - STORIES TYPE CONSTR.
EXP -
OCC.GROUP ,RES.UNITS `
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED-
DI
IGNED -
• ' ROOF SO.FT,FLOOR AREA TOTALACREAGE
DIAPHRAGM -
BUILDING USE
' - NPS - IND CON PB Omer
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED T� ❑ [I '�
ROUGH 1, ASSESSORSPARC EL NO.
' '
PLUMBING
GAS TEST
TRACT NO. PARCEL NO.
� '
MECHANICAL - -
ACC.DATE ACC FILE NO.
ELECTRICAL - FINALS DATE INSP.
FRAMING SAN # -
ZONING ENG.SITE NO.
INSULATION PLUMBING
GAS,
MECHANICAL FIRE SPRINK ENERGY TQC
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED , HEATING , Y [3 N[j Y No
LATH-INTERIOR - ELECTRICAL FLOOD20NE A.L:U.C*
LATH-EXTERIOR - FIRE DEPT. Y❑ N❑ Y ❑ NE]
SHEETROCK . - GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING
SHEAR EXTERIOR. I 'TEMPORARY APPROVALS BUILDING
FIREWALLS ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCY OF BUILDINGJS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
uJ ARRANGE FOR INSPECTION BY PHONING 252-4505,
ELECTRIC
F ONE WORKING DAY BEFORE REQUIRED INSPECTION.• PLUMBING
0� PLEASE.GIVE JOB ADDRESS WHEN PHONING.
Z - 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 IDENTIFICATION PERMIT NUMBER
waaolNc APPLICATION & PERMIT
T"C�\Uh II_L� BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 11644
f O'ANER'5 PLAN CHECK VAy DATION
i % NAME ` y-y^Q TY. ELECTRIC PERMIT FEE 44� ,n A
lPHONE2 - Y
/ CONTRACTORS
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
19' 4 el=.No. 86'Zo�h LIGHTING FIXTURES 10.00/1,00
CONTRACN3" PPLIANCES-RESIDENTIAL 4.00
-� SCCFOa�;S , /. 'IC�-IQ DJ
tµ`4..1--11� l�lo�...�tt N(FHONE OSS9--t9a PANELS 10.00 DATE OF APPLICATION
Am:HITECTPLAN CHECK FEE P.C.NO.
OR' - PANELS (OVER 200 AMP) 20.00
s NEERk?XQ1 -u4" rLic.No. '51 01175.00 SIGNS TRANS. 3.00
l ARCH.OR ENG. U•�w�Q A h P T VALID
ADDRESS ^/ SPECIAL CIRCUIT
1 ((Z W C>( be n-e {„ zlv TEMP. METER OR POLE INS. 20.00
APPLICANT
ADDRESS MOTORS SEE FEE SCH.
l .t - h I 14
_q 5- ' fT(,C4+ne� n SERVICE CHANGE 20.00 aUG
o o LICENSED CONTRACTORS DECLARATION
- IS ,I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
BLD ELECT. PLG. MECH.
F D z Professions Cole,and my license is in full fore a yyf[act. Vr 1:1 El a, 0 4 - License Chis Lic.Number .Q,2 C
0 z F _ Dale Contractor
`a , Se -�+ BUILDING PERMIT
0 i 4 OWNER-BUILDER DECLA ION INFORMATION
w ; ,m I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
Fa- 0a law for the followin,reason.(Sec.7031.5,Bisinessend Professions PERMIT ISSUANCE 10.00 VALUATION 5/FT.
Code:Any city or county which requires a N mit to constmel,eller,
i ¢ ¢ improve,demolish,or repair any steucture,prior to its issuance,alsoec ELEC.CONTR. _ LIC.N0. ELEC.
ea
D LL requires the applicant for such permit to File a signed statement that TOTAL ER MIT T
w$w he is licensed pursuant to the provisions of the Contractor's License
Fir Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
/ ¢ = the basis for the alleged exemption.Any violation of5ectfon 7031.5 STORIES TYPE CONSTR.
ate - by any applicant for a permit subjects the applicant tox civil Penalty ALTER-DRAIN -WATER IEA.) 5.00
of not mole than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and thestrucfure 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 dors not apply to an owner OI'
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 ST,FT.FLOOR AREA TOTGLACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-1 6.00
ments are not intended or offered for sale.If,however,the building
of hnprovement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or on. R IND CON PB Omar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ El El C-1❑ I,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
s. contracts for such projects with a contractions)licensed pursuant to
the Contractor's License Law. SEWER-SAN ITARY-STORM EA.200ft/10.00 TRACT No. PARCEL NO.
❑ lam exempt under Scc. .B.&P,C.for this WATER HEATER W/VENT 6.00
reason
j Owner Date WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-inso e, ZONING ENG.SITE NO.
or a certificate of Workeri Compensation Insurance,or a certified
copy thereof(Sec.3800. �DLab.C.).,^a ,
Policy No. Company lA
O ❑ Certific c py is hereby fornishcd. FIRE SPRINK ENERGY T 24
Z Z� ❑ Cert' copy is Iled wit city in etion division.
O Applican MISC.- REFER TO ORD. v❑ IN Y IN
~ In PERMIT ISSUANCE 10.00
LU -
CERTIFICATE COM E SATIONEXEMPTION FROM WORKERS' FLOOD ZONE A.L.u.C.
W >_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
1 O (This section need not he completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
Z) Z hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I Shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
a Datc A p,licam ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE '10 APPLICANT: It,after making this Certificate of Ex-
F-. Z emption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with
U such provisions or this Permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00 FEE ,
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00C.EM.) 6.00 SEISMIC FEE
1 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.) 6.00
Lendcr's Nam c HEATI NG UNIT 100,000 B.T.U.)8.50
Lenders Address ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
1 information is correct.I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-OOIvP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to en `r upon the BOILER-COMP Over 100,000BTU)SEE FEESCH. MECHANICAL
above-mentionproperty for inspection purposes,
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino a t liabilities,judgments, costs and expenses which PER ISSUANCE 10.00 CONST.TAX
may I ay accrue against�Sald City in consequence of the
IS Persalt, //n 1/'I.-/' MECH.CONT. LIC.NO. MECH. TOTAL
..-NFi/�(/t l!a-(Kl�/ S 1I� TOTAL
SiglsamraApplicant/Contnetor Date
OFFICE COPY