11228 POST THIS CARD NEAR FRONT OF BUILDING
CITY OF CUPERTINO PERA" NUMBER
- INSPECTION DIVISION
11228
' JOB INSPECTION RECORD
PERMIT EXPIRATION
JOB ADDRESS UNIT# LOT#
I I
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
LIFER
LASTCALLED INSPECTION.
PREGUNITE PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB Gr
PLUMBING
ELECTRICAL ISSUANCE DATE
MECHANICAL BLDG. ELECT.1 PLD. MECW
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED Bu1LDING PERMIT
WOOD FLOOR INFORMATION
PLUMBING VALUATION $/FT.
_ MECHANICAL
ELECTRICAL PERMTy
FRAMING LY• �%�
INSULATION ST RIBS P CONSTR.
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
,ROOF SO.FT,FLOOR AREA TOTAL ACREAGE
DIAPHRAGM'
BUILDING USE
RES IND CON PB Olnar
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑ ❑ ❑
ROUGH ASSESSORS PARCEL NO.
PLUMBING
GAS TEST TRACT NO. PARCEL NO.
MECHANICAL ,
ELECTRICAL �_ FINALSDATE INSP. ACC.DATE ACC FILE NO,
FRAMING- SAN #
INSULATION. - _ 6 PLUMBING _8 ZONING EN, SITENO.
GAS
MECHANICAL FIRE SPRINK ENERGY T 24
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y ❑ N❑ Y ❑ N❑
LATH-INTERIOR ELECTRICAL .}yam -FLOOD ZONE a.L.u.c.
LATH-EXTERIOR FIRE DEPT. Y❑ No Y ❑ N❑
SHEETROCK - GRADE
SHEAR INTERIOR FEE SUMMARY
BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING 1'e :v
FIREWALLS ELECTRIC
PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED JOCCUPANUY SEISMIC FEE
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR.
l MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
F� ONE WORKING DAY BEFORE REQUIRED INSPECTION: E,
Z PLEASE GIVE JOB ADDRESS WHEN PHONING. PLUMBING
- SEE PERMIT FOR EXPIRATION DATE = MECHANICAL . -
IMPORTANTI 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
e-BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT 11228
•�� ADIDRE55 4 �
iG S - efy
e /4f171/s OAPs 4VE BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
WNER'S PLAN CHECK VALIDATION
NAME - -I �/ Y QTY. ELECTRIC PERMIT FEE
//� //Q /l a� PHONE
CONTRACTOR'S
y NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
ADDRESS
S4�`- / C� 9�O�G APPLIANCES-RESIDENTIAL 4.00
CO ^y' fC
v � HONE PANELS 10,00 DATE OF APPLICATION
=CIAORRCHITF T PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARC H.OR ADDRESS ENG. SPECIAL CIRCUIT 5.00 - PERMIT VALloarlOru
ZIP EMP. METER OR POLE INS. . 20.00 IJA'_/-/)
ADDRESS MOTORS J EE'FE SCH.
ADDRESS
SERVICE CHANGE 20.00 W�
upeluuv LY 4
W o o LICENSED CONTRACTORS DECLARATION I J U14 ' -L U
a u I hereby affirm that I am licensed under provisions of Chapter 9 14.C. ire ISSUANCE DATE
y a n (commencing with Section 7000)of Division 3_
[hc Business and BLDG. ELECT. PLG. MECH.
O H y, Profess sTod. d my license is in full force and effect { L O
0
' 00., License Clss-.,� Li<.Number ( I C P
F y H w Uatc !_ Contractor -
m M 4 OWNER-BUILDER DECLARA'r10N s- BUILDING PERMIT
E o aU INFORMATION
X 3: u I- I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
,o ¢ Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
- g PERMIT ISSUANCE 1p,00 �3
y u Code: e,d city demolish,
county whiny structur e p riot t oc.is i shun,,also
ELEC.CONTE. LIG NO.
rc a ¢,o improve,demolish,or repair any structure,prior n its issuance,also ELEG qq
G u requires the applicant for such permit to file a signed statement that TOTAL
u w m he is licensed pursuant en the provisions of the Contractor's License PERMIT TO
z <
Law(ChapterProfessions
Code)or Section is 00)exemfttheefromion 3 the
o Business and Professions Codc)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE 7
SFm the basis for the alleged a xemplion.Any violation ofSectlon 7031.5 TORIES TYPE CONSTR.
s3 _ by any applicant for a permit subjects the applicant toacivilpenalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500)):
❑ 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 the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 5.00
Code:The Contractors License Law does not apply to an owner of
himself who builds h or improves employees,
pr and who dues such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employeese provide)that such improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or Improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4(EA.) 2.00
builder will have the rotten - .of proving that Ile did nut build or int- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB omar
❑ 1,as owner of the property,am exclusively contracting with 11 El Ellicensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 6.00 ASSESSORS PAREl 0
CEL NO.
and Professions Code:The Contractor's License Law does not apply V.S.
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 cnntructons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.I'or Ibis
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO,
WORK ERS'COM PENSATION DECLARATION WATER TREATING EQUIP, 5.00 -
1 hereby affirm that 1 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.C.I
Policy No. Company
❑ Certified u s hereby furnished. 7z7-6zaz. FIRE SPgINKENERGV T-24
Z 2 ❑ CeNified cup p led}vi If If ty inspection division.
F O� APplicant 'i MISC.- REFER TO-ORD Y E] N[:] Y [] N�
tw CER'I FICATEOF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
LLI > COMPENSATION INSURANCE: PLG.CONTE. -LIC.NO. PLG.
0- O (This section need Rot be completed if the permit is for one TOTAL v❑ N� V❑ NEI
U 0 hundred dollars(SI00)ar less,)
1 certify that in the performance of the work for which this per- GTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workeri Compensation Laws of California.
DO Date Applicant ALTER OR ADD TO MECH _ BUILDING S'�iSf a
} to NOTICE TO APPLICANT: 11,after making this Certificate of Ex- 5.00
F. 2 emption,you should become subject to the Workers'Compensation APPLIANCE 500 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 LENDING AGENCY AIR HANDLING UNIt(QV C.FM.) 6.00 SEISMIC FEE G�
I 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. -- rrt
MICROFILM
3097,GY.C.). HEATING UNIT(TC��,0bO'B:T`U.) 8.00
Lender's Name
Leader's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC 3S_V_111
1 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(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives is city to enter upon the h of this BOILER-COMP(Over 100,000 BTU)SEE FEESCH. MECHANICAL /S`�_
above-mentioned property fonnsp of 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
may in any way accrue a ainsI Said City in consequence of the PER ISSUANCE 10.00 O
I of this perm y MECH.CONT. LIC.NO. MECH.
TOTAL TOTALS
I
of Applicant/Contractor Date
OFFICE COPY