15512 POST THIS CARD NEAR FRONT OF BUILDING RN1Ii NDMBER
CITY OF CUPERTINO 15512
INSPECTION DIVISION
JOB INSPECTION RECORD
' PERMIT EXPIRATION 1
JOB ADDRESS UNIT# _LOT#
/��q, �C}�/' 4L / PERMIT EXPIRES IF WORK
OWNER / /.•G9 C (/CONTRACTOR f `-K/�-KI S G,L rC CT IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD • 180 DAYS OF PERMIT ISSU-
FOUNDATION - ANCE OR 180 DAYS.FROM
NOTE: '
LIFER" ALL GRADING AND DRAINAGE SHALL BE INSTALLED LAST CALLED INSPECTION.
PREGUNITE - TO COMPLY WITH THE APPROVED PLANS AND CIN OF PERNui VALIDATION
CUPERTINO STANDARDS. -
GARAGE SLABS .. .�,,_'+
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED / ce
UNDERGROUND /SLAB"
PLUMBING
ELECTRICAL ISSUANCE DATE
MECHANICAL BLDG ELECT I PLG. .MF.CR
❑ I W ❑ ❑
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR VALUATION SIFT,
PLUMBING BMW
MECHANICAL
_ ELECTRICAL /�/1TLIT.11 To
FRAMING T"""d
INSULATION: - STORIES, TYPE CONSIR
OCC.GROUP RES UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
SO FI FLOOR RHEA TOTAL ACREAGE
ROOF - NOTE:NO FINAL INSP.SHALL BE MADE BEFORE
DIAPHRAGM THE CONSTRUCTION TAX IS PAID
BUILDING USE
ROOF SHEATHING, Hes 'No CON BE "OIL..,
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP. ❑ ❑ ❑ ❑ ❑
ROUGH SAN.N ASSESSORS PARCEL NO
PLUMBING - . ELECT.ENERGY
TRACT NO PARCELNG
TUBS 8 SHOWER PAN PLUMBING ENERGY
MECHANICAL MECH.ENERGY
ELECTRICAL BUILDING ENERGY ACC OnrE ACC FILE No
FRAMING' - ELECT.FINAL TEST
INSULATION - PLUMBING ZONING ENG SITE NO.
GAS TEST GAS
MECHANICAL FIRE SPRINK ENERGY T 24
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING [:] "❑ F) "❑
EXTERIOR'SH EAR ELECTRICAL RELEASE FLOOD ZONE A.L.UC,
INTERIOR SHEAR FIRE DEPT. ^- Y❑ N❑ r ❑ N❑
SHEETROCK GRADE FEESUMMARY
EXTERIOR LATH - BUILDING
INTERIOR LATH TEMPORARY APPROVALS BUILDING
SCRATCH COAT ELECTRIC , PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE-HAS SIGNED JOCCUPANCY - SEISMIC FEE
' OCCUPANCYOF BUILDING ISNOTPERMITTED UNTIL BUILDING FINALISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC c• :j3z
•� �� ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING '
z PLEASE GIVE JOB ADDRESS WHEN PHONING. "
— SEE PERMIT FOR EXPIRATION DATE — MECHANICAL
IMPORTANT! A CONST.TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION: Ali
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN'ONLY
BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER ,
BDILDING APPLICATION & PERMIT
ADORES g 1, 551 Z
I 441 J BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S O� PLAN CHECK VALIDATION
NIAEE OTY- ELECTRIC PERMIT FEE
Il I '
PHONEL44)-o"
1-40 CONTRACTOR'S
NAME "1U UTLETS-SWITCHES-RECEP 10.00/1.00 00
�fiY'r S P.G LIC.ND: (4 1LIGHTING FIXTURES 10.00/1.00 �� p
ADACTafls
ADDRESS
PPLIANCES-RESIDENTIAL 4.00
939-e TUr GT. PHONE (-.p r'll�� PANELS 10.00 DATE OF APPLICATION '.
ARCHITECT, PANELS IDV ER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC NO. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT 5.00
ZIP EMP.METER OR POLE INS. 20,00
ADDRESS ADDRESSFLICANMOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
ort i
FOOy+ LICENSED CONTRACTORS DECLARATION ,
a
'I hereby affirm that I not licensed under provisions of Chapter 9 ISSUANCE DATE
I- I" (commencing with Section 7000)of Division 3 of the Business and
w ¢ A - BLDG. ELECT. PLG. MECH.
H L i License
Professions Cole,and my license is in full force and effect.
oZ m o License class it, Lie.Number-y,�.$ I .
H w H j Date-��_'(.4 C.gINNtor_f7,GV1 l" tlJCf:PIC_
¢ M F f BUILDING PERMIT
IF ¢o M OWNER-BUILDER DECLARATION INFORMATION
E
I hereby affirm that I am exempt from the Contractor's License MISC.- TO ORD
ut VALUATION E/FT.
H u o¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 ,0
Code:Any city or county which requires a permit to construct,alter,
rt ,G 0 improve,demolish,or repair any structure,prior In its issuance,also ELEC.CONTH. LIC.NO. ELEC.
a_ w requires the applicant for such permit to file a Signed Statement that TOTAL !
w2 he is licensed pursuant to the provisions of the Conlramor's License PERMIT TO
rz > is
Law.(Chapter 9(cnnhmeneing with Section 7000)of Division 3 ofthe �`eG
¢ Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE LLY
(C $ the basis far the aIle red exec lion..An .
g p the
eapplicnt f Section malty STORIES TYPECONS
by any applicant fore permit subjects lheapplicum toacivil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred Dollars($500).):
Cl I,as owner of Be properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will Jo 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
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SD.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such Improve-
ments are net intended oroffered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 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 int- RES IND CON PB Other
prove for purpose of sale). INDUSTRIAL WASTE INTER. 30.00
❑ 1,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 N0.
and Professions Code:T'he Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forsuch projectswith a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ftI10.00
the Contractors License Law. TRACT N0, PARCEL NO.
❑ I am exempt under Sea ,B.&P.C,for this
reason WATER HEATER W/VENT 6.00
Owner - Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK Ii RS'COM PENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of Consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby famished. FIRE BFRINK ENERGY R24
Z 2 ❑ Certified copy is filed with the Lily inspection division. FIRE
- REFER TO OR .Applicant y No y E] N[_]
CC N CBRTIFICA'fG OIr EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > COMPIiNSATION INSURANCE PLG,CONTH. LIC.NO. PLG,
0. Z (Phis section naed not he completed if the permit Is for one TOTAL Y[:] NE] Y ❑ rye
hundred dollars(5100)or less.)
U O I certify that in the performance of Die work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compemation Laws of California.
Date A licant BUILDING
a PP ALTER OR ADD TO MECH. 5.00
} N NOTICE-TO APPLICANT: If,after making this Certificate of lix-
f= Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must Tmthwitt comply with FEE
U such provisions or lllis permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 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 100,000 B.T.U.) 6.00
Lender's Name HEATING UNIT 100,000 B.T.U.)9.50 H. Q�
Lender's Address ELECTRIC
I certify that I have real Ibis application and state that the above VENTILATION FAN (SINGLE) 4,00
information is correct. I agree to comply with all city and county
ordinances
ordinances and state laws relating to building construction, and BOILER-COUP(3 H.P.or 100,000 B.T.U.)'6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)BEE FEE SCH. 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 10.00 CONST.TAX
may in any way accrue against rid City in consequence of the
rantmg Of tl is permit MECH.CONT. LIC.NO. MECH.
75
tj TOTAL TOTAL (q.�D
Signator A,prcan/ flactor Dale
OFFICE COPY