C 8391 POST THIS CARD NEAR FRONT OF BUILDING
PFRMIT NUMBER
r CITY OF CUPERTINO .
yrC�
INSPECTION DIVISION 839,39,
JOB INSPECTI N RECORD
• PERMIT EXPIRATION
JOB ADDRESS _!! �O IT# LOT
11 PERMIT EXPIRES IF.WORK
F
' awNER CONTRACTOR .. IS NOT STARTED WITHIN
INSPECTION DAT INSPECTOR INSPWTION C RD 180 DAYS OF PERMIT ISSU•
FOUNDATION ANCE OA-180 DAYS FROM' `
LAST CALLED INSPECTION.
UFER
PREGUNITE PERMIT VALIDATION
-POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB
PLUMBING-
ELECTRICAL � �ISSUANCE unrE '
MECHANICAL BLDG. ELECT. PLG. MEC..
F1
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR VALUATION $/FT.
PLUMBING ,
MECHANICAL
ELECTRICAL - E\( PERMIT TO
;
FRAMING
ED
INSULATION - - STORIES 1 rvP comsTR.
OCC.GROUP 'RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF SO,FT.FLOOR AREA TOTAL ACREAGE
DIAPHRAGM
BUILDING USE
R IND CON PB G,he,
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNEDElO El0
ASSESSORS PARCEL NO.
ROUGH
rGASPLUMBING --Fs-
GAS
TEST TRACT NO. PARCEL NO,
i
MECHANICAL
ACC.FILE NO.
ELECTRICAL � � FINALS DATE INSP. ACC.DATE . •
FRAMING SAN Ok
ZONING ENG.SITE N0.
INSULATION PLUMBING
GAS
MECHANICAL FIRE SPRINK ENERGY TQ4
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Yo NE] Y [3 N�
FLOOD ZONE A.L.U,C
TERI .
LATH-INOR _ ELECTRICAL. .'
LATH-EXTERIOR - FIRE DEPT. Y E] N❑ v ❑ NF]
SHEETROCK GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING
FIREWALLS ELECTRIC- - PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCY OF BUILDING ISNOTPERMITTED UNTIL BUILDING FINAL ISSIGNED BYBUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
F� ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING' Y
z PLEASE GIVE JOB ADDRESS WHEN PHONING.
- 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
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
--,X,
pppys. APPLICATION & PERMIT 3 91
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
/ WNf P'6 PLAN CHECK VALIDATION
. NAMES u��• /J/ �(i/J{, CITY. ELECTRIC PERMIT FEE
J/9+Ft/� /r`fNrGT C�PNDNE
j0 NAMERacroRs f UTLETS-SWITCHES-RECEP .10.00/1.00 S-M
PUIC.rvo. Od/ LIGHTING FIXTURES 10.00/1.00
7' ADDRRAcroR's ADDRESS APPLIANCES-RESIDENTIAL 4.00
/� /�`'l r
J T.�/J6/L.liO S�r�PHONE /7PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
oRS A-^� PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.NO. ISIGNS TRANS. 3.00
A"C"ESS Ervc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 ^
AE - p
SS �J
ADDRESS
MOTORS SEE FEE SCH. /` ,,/v[�Y/
SERVICE CHANGE Agr._20.00 -
Q �
o O LICENSED CONTRACTORS DECLARATION TEMP.POLE $0.00 /�S
¢z w 1 hereby affirm that 1 am licensed under provisions of(Chapter!) h, ,,, 1(s ❑ ISSUA CE DAT
(co nmene,ng with Section 70001 of Division 3 of the Business and a w V �vv. BLDG. LECT. PLG. MECH.
D� Professions Coe nd I' nse is in full force d C eel
z O n - License CI Lic.Number y C'� rr� s� T
9 r J )are�Contractor LV I W U al 1l❑
City of Cupertino
M m s BI�ILDING PERMIT
¢ ¢o i OWNER-BUIL DEC RATIUN - F MA .I
'xa g y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
Foo J Law for the following reason.(See.7031.5,Businessand Professions PERMIT ISSUANCES / VALUATION T.
w� Code:Any city or<ounfy which requiresa permit reconstruct,otter, ?
E,
¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, ELEC. J f/
i D M requires file applicant for such permit to file a signed statement that TOTAL PERMIT T
uAKi m he is licensed pursuant to the provisions of the Contractor's License p
w, >w Law(Chapter 9(commencing with Section 70000ofDivision 3 ofthe Al
1 4 Qo Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i3 - by any applicant for a permit subjects the applicant to a civil Penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 DEC.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,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or Improves thereon,and who does such work FIXTURES-PER TRAP 5.00 6O.FT.FLOOR AREA TOTALACREAGE
marlsfor not
ownemployees,for sale.
If,ed however,the
improve- GAS-EA.SYSTEM•I INC.4 OUTLETS 6.00
mems are nor ugh his or offered for sale.IL however,the budding
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM OVER 4 IEA) 2.00
builder will have th . - .
e burden of proving that he did not build or im- _ BUILDING USE
prove for Purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with it 1:1 ❑ 0 ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPR INKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWNSPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractots)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA,200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sac.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPF.NSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconsent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.). F opr
AW
Policy No. Company�.0
O ❑ •rlified Copy is hereby furnished.' / qq� FIRE SPRINK ENERGY T-24
Z 2 I ertifia!_d y/s fit d '!r the-ctyJrE ton division.
I- MISC.- REFER TO ORD.Ql\ Applicant Y E] N� Y C) N�
yP
LU CERTI ICEXEMPTION FROM WORKERS' PERMIT ISSUANCE 10,00 FLOOD ZONE A.L.U.C.
OF
W � COMPENSATION INSURANCE PLG.CONTR, LIC.No. ' PLG,
CL Z (This section need not be completed if the permit is for one TOTAL Y[1] NC] Y C] N�
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per. CITY. MECHANICAL PERMIT FEE FEE SUMMARY
IL F mit is issued, I shall not employ any person in any routine,so as to
0 W become subject to the Workers'Compensl tion Laws of California.
0. Date Applicant BUILDING 30P Iry
>- W NOTICE TO APPLICANT: If,after making This Certificate of lix ALTER OR ADD TO MECH. 5.00
I. Z emption,you should become subject to the Workers'Compensution APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or This permit shall be deemed revoked. AIR HANDLING UNIT ITO 10=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10MC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
rile performance of lite work for which this permit is issued See. MICROFILM
3097,Civ.C.1, HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that 1 have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00 e.�.
information is correct.I agree to comply with all city and County PLUMBING
ordinances and state laws relating to building construction, and BOILER-COW(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorise representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOI LER-COMP lover 100,000 BTU)BEE FEE BCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE ORD CONST.TAX
may in any way accrue against said City in consequence of the10.00
gEmmin of this perm MECH.CONT. LIC.NO. MECH.'
TOTAL TOTAL O ,f-o
tore of ApplicantlCon ra or le _
OFFICE COPY
)