10218 POST THIS CARD NEAR FRONT OF BUILDING
PFRMIT NUMBER
CITY OF CUPERTINO1
INSPECTION DIVISION
JOB INSPECTION RECORD
( FPERMIT EXPIRATION
JOB ADDRESS Iv -�� UNIT# LOT# '
PERMIT EXPIRES IF WORK
.. OWNER U. -� .CONTRACTOR IS NOT.STARTED.WITHIN
INSPE ION DATE INSPECTOR INSPECTION RECORD 180DAYS OFPERMIT ISSLI-
FOUNDATION I ANCE OR .180 DAYS FROM
UFER - ��JD�tY6 !/-�-'R,-•�4-"^-`�- LASTCALLED INSPECTION.
P,REG UNITE PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB
PLUMBING
ELECTRICAL ISSUANCE DATE
MECHANICAL - BLOC. LECT:I PLG. MECH. '
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
WOOD FLOOR INFORMATION
PLUMBING
VALUATION $/FT,
- -
MECHANICAL } .'
ELECTRICAL PERLM�IT TO
FRAMING
INSULATION STOHIY - TYPE CONSTR.
OCC,GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
• ROOF SO.FT.FLOOR AREA TOTAL ACREAGE
DIAPHRAGM
BUILDING USE
HE IND CON , PB O,h.,
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑ ❑
ROUGH ASSESSORS PARCEL NO. -
PLUMBING
GAS TEST - TRACT NO. - PARCEL NO.
MECHANICAL
ELECTRICALACC.OATE ACC.FILE NO.
FINALS DATE INSP.
FRAMING SAN # I.
ZONING ENG.SITENO
-
INSULATION � PLUMBING
GAS
MECHANICAL FIRE SPRINK ENERGY T-24
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y ❑ N[D Y ❑ N[:)
LATH-INTERIORELECTRICAL FLOOD ZONE A.L.U.C.
LATH'-EXTERIOR FIRE DEPT. _ _ Y❑ N❑ Y ❑ N❑
SHEETROCK B y-y GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING
. SHEAR EXTERIOR
TEMPORARY APPROVALS BUILDwG
FIREWALLS JELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
UCCUPANCV OF BUILDING IS NOTPERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
o� ONE WORKING DAY BEFORE REQUIRED INSPECTION. P�uMBING
Z PLEASE GIVE JOB ADDRESS WHEN PHONING.
- SEE PERMIT FOR EXPIRATION DATE - MECHANICAL
IMPORTANT! CONST..TAX '
PLEASE READ REVERSE SIDE BEFORE : TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY "
i
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMITNUMBER
BUILDING APPLICATION & PERMIT /� /�
aaOHEssD - 10218 0 '/ 1 8
OJS BUILDING -ELECTRICAL-PLUMBING-MECHANICAL I G fVl
OWNER'S
NAME PLAN CHECK VALIDATION
DTV. ELECTRIC PERMIT FEE
PHONE 44b s53:;
CONTRACTORS
NAMEOUTLETS•SWITCHES-RECEP 10.00/1.00
uc.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
DDRESS Offs - PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
OR
ARCHITECT PANELS IOVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER ,
uc.No. SIGNS TRANS. 3.00
ADDRESS sec' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP ITEMP,METER OR POLE INS. 20.00
n000ssTs MOTORS SEE FEE SCH.
SERVICE CHANGE' 20.00 t•�_V
Woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢ u u I hereby affirm that I am licensed under provisions of Chapter 9
z w 155 NCE DATE
y ¢w• (commencing with Section 7000)of Division 3 of the Business and BLD PLG. MECH.
H D z Professions Code,and my license is in full force and effect. ❑ ❑ ❑
Zo z H C License Class Lie.Number
H w r-.0 Date Contractor
- s
14 I P RMIT
0¢ a OWNER-BUILDER DECLARATION
o it U INFORMATION
'x ; y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD vvggl,
_ LLD ¢ Law for the following reason.(Sec.7031.5.Business and Professions 10.00 r,�}y p 190 S/FT.
PERMIT ISSUANCE ,_gtY'
ac aa j Code:Any city moronity pair any unicture permit it toconsua ce,alalter,
2 ¢ 0 improve,demolish,or repair any s[nlclure,prior m its issuance,also ELEC.CONTR. LIC.NO. ELEC.
m LL req miles the applicant for Such PC rmlt to hie a signed at atement that TOTaI
u w he is licensed pursuant la the provisions of the COmmclor's License PERMIT TO
rz> Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe
1 i o Business and Professions Code)or that he is exempt therefrom and GTV. PLUMBING PERMIT FEE
X r the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
T by any applicant for a permit subjects the applicant tea civil penally ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500t):
0 I,as owner of the properly,or my employees with wagesas BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 5.00
Code:The Contractor's 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 aD.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve
ments improvmennot t fended orofferedon yearsole.oIf,mpletion the the owner. GAS-EA.SYSTEM-11NC.4OUTLETS 8.00
7r)der will has is sold within one year he he aid ion,the owner.
builder will have the burden of proving that he did not build Or am. GAS'-EA.SYSTEM-OVER 4 (EA.) 2,00 BUILDING USE
grove 11.r
aso nee of sale,). INDUSTRIAL WASTE INTER. 30.00 RES IND CON Pg osnar
❑ d as owner of the properly,he exclusively contracting with � ❑ ❑ ❑ ❑
licensed contractors Io construct the project La 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Con t4lds o License Law Apes not apply ho
to tr owner of property who builds t r improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts fur such projects with a contracloAsl licensed Pursuant to
the Contractor's pt under
Sec. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO,
tum exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason '
Owner Datel7=7 WATER SYSTEM .5.00 ACC.OATE ACC.FILE NO.
Wo IiRS'COMPIiNSATION DIiCLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG,SITE NO.
copy thereof(Sec.3800,Lab.C.L
Policy No. Company
O O CertifiedcopyisherebylLrnisheJ. FIRE BPq INK ENERGYT]4
Z Z 0 Certified copy is filed with the city inspection division.
F O Applicant MISC.- REFER TO ORD. Y❑ N� Y ❑ N�
LA CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE AL.U.C.
LL 2 COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL ❑ (This section need not be completed if the permit is for one TOTAL Y EJ N Y [:] N
LZ) Z hundred dollars 1 S 100)or less.)
) 0 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mil is issued,1 shall not employ any person in any manner s',,as to
O w become subject to the Workers'Compensation Laws of California.
y
Date-Applicant
ALTER OR ADD TO MECH. BUILDING 3�fZ
>_ N NOTICE TO APPLICAN r: If,after making this Certificate of Ex- 5.00
I.. Z emption,you should become subject to the Workers'Compensution APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Cade, you must forthwith comply with FEE
U such provisions or this permit slsall be deemed revoked. AIR HANDLING UNIT(TO 10,ODOCF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MCEM.) 6.00 SEISMICFEE >�
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(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders Name
Lender's Address HEATING UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
Ordinances and state laws relating to building construction, and BOILER-OOMP 13 H.P.or 100,000 B.T.U.) 6,00
hereby authorize representatives of this city m enter upon the BOILER-COMP (Over 10Q000BTU)SEE FEESCH. MECHANICAL
hereby auli7ned property forinspection purposes.to.
(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
Fmay n any way accrue agar said City in consequence of the PERMIT ISSUANCE 10.00
g frog pf this permit. MECH,CONT. LIC.NO. MECH.
Z_ 1 TOTAL TOTAL
Signa[ of ApPiicxn[ 'anlraclor Ualc
- - OFFICE COPY