11454 POST THIS CARD NEAR FRONT OF BUILDING
PERMIT NUMBER
CITY OF CUPERTINO 11454
INSPECTION DIVISION
JOB INSPECTION RECORD
/97x1 Mery PERMIT EXPIRATION
JOB ADDRESS UNIT# LOT#
� LL PERMIT EXPIRES IF WORK
OWNERHhtd[trOl CONTRACTOR —, n T. IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATIONANCE OR 180 DAYS FROM
LASTCALLED INSPECTION.
UFER -
PREGUN TE PERMIIT VALIDATION
S- .
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED _
UNDERGROUND /SLAB
PLUMBING /�
ELECTRICAL �S ISSUANCE DATE
MECHANICAL BLOC, ELECT. PLG. MECW
El I El
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR
VALUATION S/FT.
PLUMBING
I
MECHANICAL
EXPIREDPERMIT TO
ELECTRICAL SWiMMrhlGi P4v�
FRAMING
STORIES TYPE CONSTR.
INSULATION
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
SO FL FLOOR AREA TOTALACREAGE
ROOF
DIAPHRAGM
BUILDING.USE
HES IND CON v8 Omre
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED 0 0 0 El
ASSESSORS V,,LL NO.
ROUGH
PLUMBING
TRACT NO, PARCEL NO
GAS TEST
MECHANICAL
ACC.DATE ACC.FILE No,
ELECTRICAL FINALS DATE INSP.
FRAMING SAN #
20NING ENG.SITE NO.
INSULATION - PLUMBING
GAS
FIRE SPANK ENERGY T$4
MECHANICAL Yo No 'Y ❑ N❑
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
FLOODZONE A.L.U.C.
LATH-INTERIOR ELECTRICAL
LATH-EXTERIOR FIRE DEPT. Y N� v N❑
SHEETROCK - GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING
FIREWALLS ELECTRIC PLAN CHECK
F
GAS EE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINALISSIGNED BY BUILDING INSPECTOR. MICROFILM
1
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
F ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
O PLEASE GIVE JOB ADDRESS WHEN PHONING.
Z - SEE PERMIT FOR EXPIRATION DATE - 1 MECHANICAL
CONST.TAX
IMPORTANT!
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION. J_
OFFICE COPY
^.NPPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT I DENTI FICATI ON PERMIT NUMBER
BGILOING APPLICATION & PERMIT 11454
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OwrvE 'S PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE
E
CONTRACTORS TEL
-SWITCHES-RECEP 10.00/1.00
j
TIC.No. LIG
�/ ✓� HTING FIXTURES 10.00/1.00
cONTRACTOR's APPLIANCES-RESIDENTIAL 4.00
ADDRESS
7 Y/0�� 2 1/.
vRONE � PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE
OR
ENGINEER
LIc,No. SIGNS TRANS. 3.00
ARCH.OR ENG, SPECIAL CIRCUIT S.00 PERMIT VALIDATION
ADDRESS
zlP EMP.METER OR POLE INS. 20.00
ASNrs MOTORS SEE FEE SCH.
ADDREDDRESS
SERVICE CHANGE ppio
20.00 V/f,'I
Er o LICENSED CONTRACTORS DECLARATION UI- '(
¢u w I eby affirm that I am licensed under provisions of Chapter 9 �(�{C7 ,C_ J 'r`) ISSUANCE DA
¢ z ( omme cin with Secs ion 000)of Division 3 of[hc Business and
6 - BLDG./s+ L MECH.
F Professi ns C e. I�,�L�n ¢cosi is in full fort➢'.tRlt' feDly ❑ y l� ❑ ❑
o Li Lens I' Lic.Number 7
s - D CDntraCtpr of CuPe��no
F
BUILDING PERMIT
¢ ¢ OWNER-BUILDER DECLARATION INFORMATION
K
o a O MISC.- REFER TO ORD
w ; w I hereby affirm that I am exempt from the Business
and
Professions
License
Foo J CLaw ode:Any citylowingreasov.(Sec.7031.S,erminessand Professions PERMIT ISSUANCE 10.00 (VALUATION $/FT.
Code:Any mulish Lou my which structure.prior
o its issuance,
alter, O �U d-y/`e�
u, 5 Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC. 3
O LL requires the applicant for such permit to file a signed Statement that TOTALS PERMIT TO
w$ he is licensed pursuant to the provisions of the Contractor's License [i 'js
H z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe V Q/!a'-t!-f/N 6`rDO L
¢ Business and Professions Code)or that he is exempt therefrom and QTY- PLUMBING PERMIT FEE
¢r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n ; ?s by any applicant lora permit subject,the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(SS00).):
❑ 1,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,COND. 5.00
Code:The Contractors 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
i� himself m through his own employees provided that such improve.
memTIES If
through
et or employeeffered for saprovided what such
building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement 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 im-
prove for purpose of sale.). INDUSTRIALWASTE INTER. 30.00 RES IND CON PB usher
❑ 1,as owner of the properly,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V 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-OV .) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200It/;1V.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sec.-.B&P.C.for this WATER HEATER W/V N,%_, i(' 6.00
reason
Owner Date WATER SYSTEM ACC.DATE ACC.FILE N0,
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQ To" 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers Cum�/pa'�r/s��u�l��oity`--I tsm�ance,or a ce Icd ZONING ENG.SITE N0.
copy thereof(Sec.3800,Lab.C�'/moi ur rC.eL� pea h v '-
Policy No. Compan; -- - -
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z 2 ❑ Certified copy is riled with the city inspection division. MISC.- REFER TO ORD.
Applicant Y ❑ N❑ Y ❑ N❑
i y CF-RTIFICATI:OF EXEMPTION PROM WORK[iR5' PERMIT ISSUANCE 10.00 d FLOOD ZONE A.L.U.C.
W >_ COMPENSATION INSURANCE PIG.cONTR. LIC.NO. PLG. 0 +y' Y N Y N
C O (This section need not be completed if the permit is for one TOTAL ❑ ❑ ❑ ❑
:D Z hundred dollars($100)or less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
ly H- mit is issued,I shall not employ any person in any manner so as to
Um become subject to the Workers'Compensation Laws of California. BUILDING
a. Date Applicant ALTER OR ADD TO MECH. 5.00
O
} rn NOTICE TO APPLICANT: IL 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 must forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10.13MC.F.M.) 4.00
CONS'T'RUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER I0=C.EM.) 6.00 SEISMIC FEE
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. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,0 .U.) 8.00
Lender's Name HEATING UNIT IO VERIMbB.TU.18.50 ELECTRIC 3 �
Lender's Addicts
1 certify that I have read this application and state that the above V ENTI LATION FAN (SING ) 4.00
information is correct. I agree to comply with all city and countyPLUMBING D
•, ordinances and stale laws relating 10 building construction, and BOILER-COMP(3H,P.o A ,0 B.T.U.)
hereby authorise representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU 6% SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- R TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 r/ (� CONST.TAX
may in any way accrue against said City in consequence of the
of permit. / MECH.CONT. LIG NO. TECW
OTAL q p-� TOTAL SS
O_ O
Ignature of Applicant Contractor )ale
OFFICE COPY