11123 POST THIS CARD NEAR FRONT OF BUILDING PF
1 CITY OF CUPERTINO "1T1u7E23
INSPECTION DIVISION
JOB INSPECTION RECORD
PERMIT EXPIRATION
JOB ADDRESS UNIT# LOT# PI
PERMIT EXPIRES IF WORK
OWNER CONTRACTOR IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION S 2SwL(C- ANCE OR 180 DAYS FROM
LASTCALLED INSPECTION:
UFER
PERMIT VALIDATION E
PREGUNITE
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB i
PLUMBING
ATE
ELECTRICAL ELECT.
uPLLG,G
MECN.
MECHANICAL 6106. ELE
El 0
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR VALUATION s/FT.
PLUMBING "•
MECHANICAL
ARCTAL t PERMIT TO
IP
ELECTRICAL
FRAMING
STORIES 'TV PE CONSTR.
INSULATION
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED -
SO.FT.FLOOR AREA TOTAL ACREAGE
ROOF
BUILDING USE
RES IND CONON PB CON
DIAPHRAGM El
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED El ❑ EL
ASSESSORS PARCEL NO.
ROUGH
PLUMBING / (� Ute✓'✓tet TRACT NO. PARCEL NO
GAS TEST
MECHANICAL
ACC.DATE ACC FILE N0.
ELECTRICAL FINALS DATE INSP.
FRAMING —,.• �(b SAN # ZONING ENG.SITE NO.
INSULATION PLUMBING
GAS
FIRE SPRINK ENERGY T 2
MECHANICAL Y ❑ NE] Y ❑ NF]
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING FLOOD LONE A.L.U.C.
LATH—INTERIOR ELECTRICAL
LATH—EXTERIOR FIRE DEPT. v NE] v N
❑
SHEETROCK _Z(p b GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING
BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS
FIREWALLS ELECTRIC PLAN CHECK
FEE
GAS
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCY OF BUILDING ISNOTPERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
H ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
1 O� PLEASE GIVE JOB ADDRESS WHEN PHONING.
/ Z MECHANICAL
- SEE PERMIT FOR EXPIRATION DATE -
CONST.TAX
IMPORTANT!
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY
APP..-_ICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENT[FICATION PERMIT NUMBER
aDILDING
Ty a APPLICATION & PERMIT
ANDRESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL/d/O f /
11123
OWNER'S
PLAN CHEC VALIDATIpN
NAME / OTY. ELECTRIC PERMIT EE -vf� \l
.9 Q'2-X .L H C. a PHONE 7 S
cANTRAcroHs UTLETS-SWITCHES-RECEP 10.00/1.00 -
NA E p // _ya
JC No Ze �8 b LIGHTING FIXTURES 10.00/1.0
CONT ACTOR'S 377-Zbl 6 APPLIANCES-RESIDENTIAL 4.00
ADO. ss
s �rPANELS IO.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
GINE
N
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG, 5.0 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT r1
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE F-EE SCH.
A Ssfy 7-3 p r J
S yN SERVICE CHANGE 20.00 nC
o o LICENSED CO TRACTORS DECLARA71ON _ 1�t{r� < r�1•U�'Sl� (7
a ar+u I hereby affirm that 1 am licensed under provisions of Chapter 9 (}1 t` s Mist O ISSUANCE DATE
e,Q m (commencing with Section 7000)of Division 3 of the Business and - .-C BLDG. ELECT. PLG. MECH.
r N z Professions Code,an ty license is in full f e def t ❑ ❑ ❑
,e o u. - License Clas Lie.Number / •,'.r �(
Q Da[c_'=�1y2�Cnntrador C r
¢ Q w ¢ OWNER-BUILDER DECLARA ION BUILDING PERMIT
U REFER TO ORD INFORMATION
wLL H I hereby affirm that 1 am exempt from th Contractor's License MISC.- VALUATION $/FT.
o a Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 A4Code:Any city or county which requires a Permit to construct,alter,
¢ ¢ Q 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
0 ca DLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT T
n
3
w m he is licensed pursuant to the provisions of the Contractor's License _
rzi
Law(Chapter 9(Commencing with Section 7000)of Divisionoflhe /^/7"4�' A
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
r cthe basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a; W by any applicant for a permit subjects the vpplicantmaCivil Penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).:
O I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Cade:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 SQ,FT FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-ments are not intended or offered for sale.If,however,the building GA$-EA.SVSTEM-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 im- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
O I,as owner of the properly,am exclusively contracting with El C-1 13 11 11licensed contractors to construct the project(See. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contrvmoi s License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL No..
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VEN1T1'_ 6.00
reason
Owner Dote WATER SYSTEM 1.-. ^E ry 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP:, .• �.1` 5.00
I hereby affirm that I have a carlil icate of consent to self-insure, `1lr • zONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a Certified
copy thercof(Sec.3800,Lab.C.1.
Policy No- ComPanYd-T,+.rc �-
O ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T 24
_Z Z >tCertified a py ix filed i the 'ily e- 6 division. MISC.- REFER TO ORD. y❑ ry❑ y ❑ NC]APPlicun[
H yPERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C.
- CERTI'IC PE OF EXEMPTION PROM WORKfiRS'
W >_ COMPCNSATION INSURANCE: PLG.CONTR. LIC.NO. PLG.
d a mit([his section need not be completed if the peris for one TOTA Y❑ N❑ Y❑ NE]
Z hundred dollars IS 100)or less.)
(„) O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensution Lows of California. UILDING
Date Applicant ALTER OR ADD TO MECH. 5.00
} ran NOTICE TO APPLICANT. If,after making this Certificate of Ex-
F Z emption,you should become subject to the WorkersCompensation 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(TO.10)D000.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNMOVER I0,000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT')' 3 5.00
the performance of the work for which this Permit is issued(Sec. HEATING UNIT(TOr100,000 B.T.U.) 8.00 MICROFILM
3097,Civ C.).
Lender's Name HEATI NG UNIT(OVER 100,000 S.T:U.)9.50 ELECTRIC
Lender's Address
I certify that 1 have read this application and state that the above L VENTILATION FAWSINGLE) 4.00
•, mr...ratio. is cornea.1 agree In comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING v
ordinances and stat, laws relating to building construction, and
hereby authorise representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL 3,
above-mentioned property for inspection purposes.
(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
mIy in any way accrue against said City in conseq Ree of the PERMIT ISSUANCE 10.00
granlin fthispermit MECH.CONT. LIO.NO. MECH.
!�. J TOTA TOTAL
`
' igna ur of App Applicant/Comractor etc
OFFICE COPY