12849 I
POST THIS CARD NEAR FRONT OF BUILDING
PERMIT NUMBER
CITY 0_F CUPERTINO 1.2849
INSACTIC N DIVISION
49ANSPECTION RECORD
PERMIT EXPIRATION
JOB ADD ESS, O✓ T# ' lOT# PERMIT EXPIRES IF WORK
OWN ER co"rRACTO ' IS NOT STARTED WITHIN
INSP ON DATE INSPECTOR INSPECTION RECORD 180 DAYS OF'PERMIT ISSU.-
FOUNDATIO ANCE OR 180 DAYS FROM
UFER
.LAST CALLED INSPECTION.
.� � - '
PERMIT VALIDATION
PREGUNITE
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED I
UNDERGROUND /SLAB /�,�.Z�jlSP
PLUMBING
ELECTRICAL ISSUANCE DATE
• MECHANICAL BL c. E PLG. MECH.
❑ ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED - BUILDING PERMIT
WOOD FLOOR
_ INFORMATION
yALUAIION siFT..
PLUMBING � y
y�C
MECHANICAL -
ELECTRICAL -- y E-/�I/yO
FRAMING- ��
"STORIES TYPE CONSTR.-
INSULATION -
OCC.GROUP - RES,UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
/ SO.FT.FLDOR nREA TOTAL ACREAGE
ROOF
DIAPHR M J
BUILDING USE
'S IND CON PB Ome.
. . APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED
ASSESSOR S PARCEL NO.
ROUGH
• PLUMBING -
GAS TEST - - TRACT N0, PARCEL NO.
MECHANICAL
ACC.DATE ACC.FILE NO,
ELECTRICAL FINALS DATE INSP.
FRAMING - - SAN OF, .
` ZONING ENG.SITE NO.
INSULATIONPLUMBING •
GA
' FIRE SPRINK ENERGY T-]<
M CHANICAL
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED ATI NG - NE] N[-]
FLOODZONE A.L.U.C.
. , LATH—INTERIOR - LECTRCAL — L �� N[_ v � NE]
_ I .
RE DEP
SHEETROCK G - FEE SUMMARY
` SHEAR INTERIOR ' BUILDINGO- 'I.
SHEAR EXTERIOR TEMPORARY APPROVALS-
FIREWALLS
PPROVALS - BUILDING
FIREWALLS ELECTRIC PLAN CHECK r y
GAS ' FEE .,.r
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED, OCCUPANCY - SEISMIC FEED
• OCCUPANCY.OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED.BY BUILDING INSPECTOR. MICROFILM
E FOR INSPECTION BY PH N ELECTRIC
ARRAN
G OPHONING N G 252-4505;
F� ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
O PLEASE GIVE JOB ADDRESS WHEN PHONING.
Z - ,
_— SEE PERMIT FOR EXP.I_RATION DATE —
MECHANICAL'
• CONST.TAX
IMPORTANT!
PLEASE READ REVERSE SIDE BEFORE TOTAL. d
CALLING FOR FINAL.INSPECTION:
OFFICECOPY -
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
BUI CDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
T AooREss // t ,, - . .- 12849
v 8-411LDING--ELECTRICAL-PLUMBING-MECHANICAL
OxNEH ( � PL AN CHECK VALIDATION
N%1'l�i/1-t. M -_�jI�oNE al •�14z OTY ELECTRIC PERMIT FEE
.� CONTRACTORS b UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LIC.NO, LIGHTING FIXTURES 10.00/1.00
ADTRARE, ORs PPLIANCES-RESIDENTIAL 4.00
CONO
PHONE PANELS 10.00 DATE OF APPLICATIO N,
ARCHITECT - PANELS (OVER 200 AMP) 20.00 PLANCHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
AGO=ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
i,IP TEMP.METER OR POLE INS.. 20.00 P
APPLICANTS MOTORS S H.
ADDRESS nn--TT
SERVICE CHANGE 20. 1-EEA
ao o LICENSED CONTRACTORS DECLARATION 1'
is i w 1 hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Basin and i fie. BLD ELECT. PLG. MECH.
H i Professions Code,and my license Is in full force and effect M UUM
❑ El ❑ ❑
z 0'J', - License Clas Lie.Number
Due Contractor
a y f BUILDING PERMIT
¢ Se w S OWNER-BUILDER DECLARATION INFORMATION
a0s MISC.- REFER TO ORD
w 3: LL H 1 hereby affirm that I am exempt from the Contractor's License VALUATION 5/FT.
HnoLaw for the following reason(Sea 703L5,Businasvnd Professions PERMIT ISSUANCE 10.00 6 -
Code:Any city or County which requires a permit to construct,alter, T _
¢ Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.GONER. LIC.NO. ELEC. /
O LL requires the applicant for such permit to file a signed statement that TOTAL ` PERMIT TO
w $ he is licensed pursuant to the provisions of the Contractor's Littnsc
zi Law(Chapter 9(Commencing with Section 7000)of Division 3 ofthe
a Busines and Professions Code)or that he is exempt therefrom unit OTY. PLUMBING PERMIT FEE
Ei0
¢ '-$ the basis for the alleged exemption.Any violation of Section
7031.5 STORIES TYPE CONSTR.
n by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5$001.): '
❑ 1,as owner of the propsity,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 o not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Luw does not apply to an owner of
_ property who builds or improves thercon,and who does such work FIXTURES-PER TRAP 5.00 sa FT.FLOOR AREA TOTAL ACREAGE
_ himself or through his own employees,provided that such improve-
ments are mol intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I1NC.40UTLETS 6.00
or impressment is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
prove for purpose ofmle.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Our.,
❑ 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:'I he Contractor's License Law docs not apply
to an owner of property who builds or improves thereon.and who ILAWN SPRINKLERS-OVER 5(EA.) 1.00
Contracts forsuch projectswith.cantracteds)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACTNO. PARCEL NO.
❑ lent exempt under Sec. ,B.CIP.C.for this - WATER HEATER W/VENT 6.00
reasol
P Owrlcr D.b,_Z. WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
WORK ERS'COMPENSA'IION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-inwre. ZONING
a certificate of Worker'Compensation Insurance,or a certified ENG.SITE NO.
,opy fl creof(See.3800,W4C). -
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T.]4
Z Z Z Certified copy is fled with the city inspection division.
O Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
CC rn CERTIFICATE OI'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.LU.C.
LI COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL 0( This section need mol he completed if the peon
noil is for e TOTAL Y❑ N❑ Y F] NE]
hundred dollars IS 100)or less.)
U 0 - 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mil is issued. I shall not employ any person in any manner Co as to
U become subject to the Workers'Compensation Laws of California.
i Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
} Co NOTICE TO APPLICANT: If,after making the Certificate of Ex-
H ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECKZ-
provisions of the Labor Code, you mus( forthwith Comply with FEE oC J
C.T such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.NL) 4.00 `
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER 10MOC.F.M.) 6.0J
0 SEISMIC FEE -0
I hereby,affirm that there is . 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 Namc HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC db
Lender's Address
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 sub, laws relating to building construction, and BOILER-COW(3 H.P.or 100,000 B.T.U.) 6.00
hereby vuthorio, representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOI LER-COMP (Over 100,100 BTU)SEE FEE SCH. MECHANICAL
(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
may in any way accrue against mid City in Consequence of the PERMIT ISSUANCE 10.00 -
nlingofth permit. MECH.CONT. LIC.NO. MECH.
Z 20 DEAL, TOTAL �169A
ignature of Applicant/ ontractor Date
OFFICE COPY /f I ,5't.