12264 POST THIS CARD,NEAR FRONT OF BUILDING
264
PERMIT NUMBER
CITY OF CUPERTINO 21
INSPECTION DIVISION
JOB INSPECTION RECORD
110- PERMIT EXPIRATION
JOB ADDR ESS S]`�"� UN IT LOT#
PERMIT EXPIRES IF WORK
OWNER' CONTRACTOR IS' NOT STARTED WITHIN
I PECTION DATE INSPECTOR 1 SP ECTIONZECO180 DAYS OF PERMIT ISSU.
FOUNDATION - okv I^ ANC. OR 180 DAYS FROM
LASTCALLED INSPECTION.
UFER
PR EGUNITE
PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED �-
UNDERGROUND /SLAB
PLUMBING. I
ELECTRICAL
ISSUANCE DATE
MECHANICAL R� �. ELECT. PLG, MECH.
El E El
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
WOOD FLOOR INFORMATION
PLUMBING VALUATION $/FT.
MECHANICAL
ELECTRICAL ^�//� 1 PERTlTO
FRAMING
INSULATION
$TORT'S TYPE CONSTR.
� - -
OCG GROUP. RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF SO.IT.FLOORAREA TOTALACREAGE
DIAPHRAGM
BUILDING USE
C
IjE IND CON PB Otner
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED &I ❑ O ❑ ❑
ROUGH ASSESSORS PARC E L NO.
PLUMBING
GAS TEST TRACT NO. PARCEL NO.
MECHANICAL
ELECTRICAL FINALS DATE INSP. ACC.DATE ACC.FILE NO.
FRAMING SAN #
INSULATION PLUMBING ZONING ENG.SITE No.
GAS
MECHANICAL FIRE SPRINK ENERGY T 24
COVER NO WORK UNTIL ABOVE HAS BEEN S GNED HEATING - Y ❑ "❑ Y ❑ N❑
LATH-INTERIOR 1- ELECTRICAL FLooD ZONE A.L.u.c.
LATH-EXTERIORFIRE DEPT. Y❑ No Y ❑ NE]
SHEETROCK GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING
SHEAR EXTERIORTEMPORARY APPROVALS Bu1LDING
FIREWALLS ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED JOCCUPANCY SEISMIC FEE
OCCUPANCY OF BUILDING ISNOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
0ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
� ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
PLEASE GIVE JOB ADDRESS WHEN PHONING.
- SEE PERMIT FOR EXPIRATION DATE - MECHANICAL
IMPORTANT! CONST.TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL I
CALLING FOR FINAL INSPECTION. J j
OFFICE COPY .
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BrrLDI G-ELEUTRI AI, PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL (� C IS /1
BUILDING DIVISION BUILDINGPR(URC'1'IDENTIFICATION LJ3 F6
BUILDING ADDRESS: G) SANITARY NO. APPLIICCA�TI/OaNSU�B.MfITALDAIL
LOT#
_�WNERS NAMI?: 10 E: CONTRACTOR'S NAME: LIC
N(C CONTROL#
ARCHIT:C /ENGIN ER: LIC NO: ADDRESS • ❑
coNrncr: puonE: QTY., ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB iCH
PERMIT ISSUANCE
El 1:1 11
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
- ION
4)MZ IherebyafOrm at Nlam licensed underprovislons of Chapters)commencing with LOB DESCRIPTION
WOO Section 7000)of Division 3 of the Business and Professions Cade,and my license is in PANELS �O ,�A1 _
FFZF L force ande <L Lic.# �I UP T02p0AMPS
1 �✓ `—
F,Q=y Date ContrnaJ �� [S W G(V(r� 201-1000 AMPS
P OrnZ s UITECTS DECLIRA ION `V OVER Iqp AMPS SQ.FT.FLOOR AREA S/SQ.FT.
I
"nor
r my plans sM1all be used as public records.
SIGNS ELECTRICAL
Y—Ej Licensed Profcvvional
y rdQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. y-
sl 1 hereby affirm that 1 am exempt from Ne Contractors License law for Ne 1
y 3,y following reason.(Section 7031.5,Business and Professions Cade:Any city ea county TEMP.METER OR POLE INST. -, 1^^ (,�
ON; which require.a permit to construct,alter,improve,demolish,or repair any structure �! !I I. IL.(
prior to its issuance,also requires the applicant for.such permit to file a signed statement POWER DEVICES II I� G l
y C 000 that he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapter
>•axo� 9(commencing with Section 7000)ofDivisinn3ofthe Busineeaard Professions Code) SWIMMING POOL ELIiCIRIC DA'T "attaill VAIJJATION
W_w or that he ix exempt herefrom and the basis for the alleged exemption.Any violation of OIII'Llil'S-SWITCHES-FIX
Section 7031.5 by any applicant fora permit subjeets the applicant too civil penalty of
FFI
oro Nnnfivchundreddollars(SSW). NEW RESIDENTIALELECR _SQ.PT.
C� ❑timml.axownerulTheprnperty.armyemploymswiN wagesavheirsolecompensa0on. STORIES TYPECONSTRUCTION
a3_ will do the work,and the structure is not intendedor offered frrsale(Scc.7044,Business
and Professions Coale:The Contramoes License Law does not apply to an owner of
pruperty wbolouldsorimprrves Nermn,and whodoessuch work himselforNrvugh his
OCC GROUP
employees,providedthat such impmvemcntsioc not imendcdoroffeedi forsale.If.
RES.UNITS
however,the building or improvement is sold within one year of completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
❑ I,asowneTope
ftheprony,emexclusivelycontmetingwithlleen,Ndonlatorsta QTY' PLUMBING PERMIT FEE FI COD/ONE APN
L,nstruct the project(Sat.7 W.Business and Professions Cud,) Me Coatracwra
icense lawdeasnot apply toanownerofpropenywho builds or improves dtereonand PERMIT ISSUANCE
who contracts for such projects with a<ontraetons)licensed formation to the Contractor x
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 on,exempt under Sm. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN_
Owner Date DRAINS-FLOOR.ROOF,AREA.COND. RECEIPfp
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ T hereby affnmtha�hove acenifeate ofemisma to self-i nn.re,ora cenifeme of
Workers CompensationT surance or a FIXTURES-PER TRAP RFCEIPI'p
n certified copy N<rerf(Sec.3g00.IsbCJ which PARK FEE YN
vers of yplyleLyrndr{a4s hermit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy ((��5 111
BUILDING DIVISION FEES
any GAS-EA.SYSTEM-OVER 4(FA)
Crnified an,is hereby famished. PLANCBECK FEE
Cenified copy is filed withfie city inspection division. GREASLANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEF.
COMPENSATION INSURANCE
(Thissection need not be completed ifthe permit is Laterite hundred dollars(Spao SEWER-SANITARY-STORM PA.200FT.
or less.) ENERGY FEE
I cenify Nm in Ne performance of Ne work for whoehmis permit is issued,)shall WATER HEATER W/VI:NT/EI.ECTR
not employ any person in any manner so as to become subjmt to the Workers PAID
z Copmpersnionl-rwsof California. Date WATER SYSTEMOREATTNG Data Rm<iptp
Z0 NOTICF,'I'0 APPLICANT.If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ,Ff. TOTAL:
rbecome subject ..he Workers Compensation provisions of the Labor Cade,you must
Y7 fonhwitb comply with such provisions or this permit shall be deemed revoked. BUILDING IEE
yCONSTRUCTION LENDING AGENCY SEISMIC FEE
Z) z I hereby affirm Nn fluor,is a cnnimillion lending agency for the performance of
O the work Ibr which Nis permit is flood(See.3097.Civ.C) TOTAL: ELECTRIC FEE
tenders Name
ULenders Address QTY. MECHANICAL PERMIT' FEE PLUMBING FEE
„ D-1 1 cenify that 1 have read this application and slate that the above information is
6. correct. Iagree to comply with all city and county otrimmua and was laws relating to PERMIT ISSUANCE MECHANICAL FEE
y buildingcttm+vumion,and hereby,a-fismaerepresemmtiveamfthis city to cnmrupnnrhe
j Z above-mentioned property for inspcmion purposes. ALTER OR ADDTO MECH. CONSTRUCTIONTAX
(We)agree to save,indemnify and keep harmless the City of Cupertino agaimr
liabilities,judgments,costs and expenses which may,.any w ynccruea mustard City AIR HANDLING UNIT(TO I n bull CFM)
I.consequence of the gran&(of this pernit.
AIR HANDL-LNG UNIT(OVER 10,000 CFM)
gnature of ApplieunVCncloe Da EXHAUST HOOD(W/DUCT)
PAID
IIA OUS MATERIALS DISCLOSURE HEATING UNIT(TO IOQIXIO BT'Of Oam Reeei
Will the applicant or future building mcupnm store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and Ne Heehh and Safety HEATING UNIT(OVER 10Q000 BTI) TO'I AL
Cod,Section 25532(a)?
❑Yes 0 N VENTILATION PAN(SINGLE RESID)
Wo,air combinations sbuilding by the
may equipment Quality
ManagM1emit
BOILER-COMP(3HP OR 100,010 BTU) ISSUANCE DA
arvdous air comominanu na defined by the Bay Area Air Quality Management BOILER-
)istrict? COMP(OVER IOO,WO BTU)
Lbuil ❑Yes ❑No NEW RESIDEN'T'IAL MECH. SQ.FT.
ding�ts,amco,mu,
ad the hazardous materials requirements under Chapter 6.95 of the #"' A , D
th&Safety Qde,Sections 25505,25533 and 25534. I understand Nat
oesnoresents yich ustbe thatit is mysuaneoila ternotify Ne reyvirements which must Ix met prim tu issuance of n Ccnifi<ate ofr><d agent Date rf .. iS,<uedlilE '�
I OFFICE