12300 'POST THIS CARD NEAR FRONT OF BUILDING
PFRMIT NUMBOR ,
�.' CITY OF .CUPERTINO 12300
INSPECTION DIVISION
" JOB INSPECTION RECORD
PERMIT EXPIRATION
JOB ADDRESS LOT
PERMIT EXPIRES IF WORK
OWNER ,NTRACTOR , IS NOT STARTED WITHIN
R
ECTION A' E" INSPECTOR INSPECTI RE OR 180 DAYSOF PERMIT ISSU-- 'ANCE OR -180.DAYS FROM
LASTCALLED INSPECTION.
PERMIT VAuOArION
NCRETE UNTIL ABOVE HAS BEEN SIGNEDUNDERGROUND /SLABr
ELECTRICAL - - ISSUANCE DATE
MECHANICAL - BLDG. ELECT. PLG. MC.
E .
0 0 O 0
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
. WOOD FLOOR --------VALUATIONsiPT.
PLUMBING - - -
MECHANICAL •yam
PERMIT TO
ELECTRICAL '
.FRAMING
INSULATION ' • STORIESTY P,E CONSTR.
OCC.GROUP RES,UNITS
_ PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
50'F i.FLOOR AREA TOTAL ACREAGE
ROOF -
DIAPHRAGM
-BUILDING USE
RES IND CON PB O,nr,
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED -ElEl0 C] 0
ASSESSORSPARCELNO. -
ROUGH
PLUMBING
TRACT NO. PARCEL NO.
GAS TEST -
MECHANICAL
ACC.DATE -.ACC.FILE NO.
ELECTRICAL FINALS DATE INSP. -
FRAMING SAN..# -
ZONING. '. ENG.SITE NO.,;
INSULATION PLUMBING
GAS
FIRE SPRINK. ENERGY T.24
- •• - MECHANICAL Y.[:] ' N[:]' YO N�
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
FLODO ZONE A.L.U.C.
LATH-INTERIOR ELECTRICAL
LATH-EXTERIOR FIRE DEPT. .Y El Y 0 rv0
SHEETROCK GRADE - FEE SUMMARY
SHEAR INTERIOR BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING
FIREWALLS ELECTRIC - PLAN CHECK
FEE
GAS
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY ' ' SEISMIC FEE G y.
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BVBUI LDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC • '
F ONE WORKING DAY BEFORE REQUIRED INSPECTION'. PLUMBING "
O� PLEASE GIVE JOB ADDRESS WHEN PHONING.
pr` Z — SEE PERMIT FOR EXPIRATION DATE' MECHANICAL
IMPORTANT'! corysT.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
BU I LDING PROJECT IDENTIFICATION L(9 r` PERMIT NUMBER
nD0.DING ' APPLICATION & PERMIT n
ADDREES O O
I p -G 2 O�/VCO� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL v
OW E_R/'S I PLAN CHECK VALIDATION,
NAME .�• QTY. ELECTRIC PERMIT FEE
/ NA � 055 PHONE
CONTRACTORS UTLETS:SWITCHES-RECEP 10.00/1.00
/ NAME
LIC.NO, LIGHTING FIXTURES 10.00/1.00 /
CONTRACTORS APPLIANCES RESIDENTIAL 4.00
A /
ADDRESSDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS IOVER 200 AMPI 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
- uc.NO. SIGNS TRANS. a 3.00
ARCH.OR ENG. - 5.00 PERMIT VALIDATION
ADDRESS' SPECIALCIRCUIT n
ZIP EMP.METER OR POLE INS.. 20.00
APPLICANT'S MOTORS SEE FEE SCH. ✓I-r/t)r
ADDRESS
SERVICE CHANGE 20.00
02 LICENSED CONTRACTORS DECLARATION
a v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y a w (commencing with Section 7000)of Division 3 of the Basi.es5 and BLDG. ELECT. PLG. MECH.
F w z Professions Code,and my license is in full force and effect. ❑ ❑ El
z o u,- License Class Lia Number -
o z w Date Contractor
a x J - BUILDING PERMIT
rc ¢ w¢ OWNER-13UILDIiR DGCLARA'I'ION INFORMATION
O REFER TO ORD
w3 u m I hereby affirm that 1 am exempt from the Contractor's License MISC.- - VALUATION - $/FT.
LL o J Law for the following reason.(Sec.7031.5.Busi.vS,.ad Professions PERMIT ISSUANCE 10.00 10 /
Code:Any city or county which requires a permit to construct,alter,
¢ a a improve,demolish,Or repair any structure,prior to its issuance,also ELEC.CONTR. LIC N0. ELEC.
G ¢ requires the applicant for such permit to file a signed statement that TOTAL Y' PERMIT TO' ,
wm" he is licensed pursuant to the provisions of the Contractor's License
F z a
Law(Chapter 9(commencing with Section 7000)of Division 3 of lire
s 4 D Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
ce H $ the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
d ; by any applicant for a permit subjects lire applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.). 5.00
of not more than five hundred dollars(S500).):
❑ I,as owner of the property,or my employees with wages as ggCK F LOW PROTECT.DEVICE 4.00 [O:CTC.GROUP _RES.UNITS
their sole eompiarmtion,will do the work,and the structure is no[
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 -
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 _ .PED G AREA TOTAL ACREAGE
�\ hinsseltor through his own employees,provided that such improve-
menti are not intended or offered for sale.If.hhweve4 the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is Sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 IEA.) 2.00 owner- BU LOING USE
builder will have the burden of proving that he Aid not build or ire- . RES IND CON Pe Ode,
prove for purpose of sale.). INDUSTRIALWASTE INTER. 30.00
❑ 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 does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a contractorts)licensed pursuant to SEWER-SANITAR V-STORM EA.200ft/10.00 TRACT NO. PARCEL NO,
the Contractor's License Law. - ,
❑ lam exempt under Sec .B.&P.C.lit'Ibis WATER HEATER W/VENT 6.00
reason
Owner J(,FC'_ UutC 6 WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate of consent to sell'-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified.
copy lhereof(Sce.3800,Lab.C.).
Policy No. Company -
O ❑ Cerlil,Td copy is hereby fur.fished. FIRE SPRINK ENERGY T-24
Z_ Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD, y N� y N�
Applicant
F-' y
CERTIFICATE OP EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
-
QJ > COMPENSATION INSURANCE PLG.CONTR. - LIC.NO, PLG. Y[ N� YC3 NE]
CL ❑ (This Section need not be wrrplcad if (lie permit is for one TOTAL
Z hundred dollars(S10()or less.) -
U O I certify that in the performance of the work for which this Per DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner Ms as to
O w become subject to the Workers'Compensation Laws of California.
Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING /D
} N NOTICE TO APPLICANT: If,after making this Certificate of F-x-
F ? emptiun,you should become subject In tire Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you nest forthwith comply with FEE
U 'such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000GF.M) 4.00 /
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE S -
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(Sea MICROFILM
3097,Civ.CJ. ) < HEATING UNIT(TO 100,000 B.T.U.) 8.00
` Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Leader's y that s ,
,I certify the I have read this application and state That the above V ENTILATION�FAN (SINGLE) 4.00
nformalion is correct. I agree to comply with all city and county PLUMBING
.�
ordinances and state Taws relating to building construction, and
BOILER-COMP I3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives ec this city eenter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
'
above-mentioned property for inspection purposes.
purpo .
- (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 accrueagainst said City in consequence of the PERMIT ISSUANCE 10.00
grand gof thispermit. /'y` MECH.CONT.- LIG NO. MECH. 0
P� 1l s� `� 11 D // TOTAL TOTAL
Signal re'o pphcanl/Contractor
OFFICE COPY