11614 POST THIS CARD NEAR FRONT OF BUILDING
PFRMIt NUMBER
CITY OF CUPERTINO 11614
INSPECTION DIVISION
JOB INSPECTION RECORD
• Q/�� , /' PERMIT EXPIRATION
JOBADDRESS� N '✓Ov` ' UNIT# LOT#
�` PERMIT EXPIRES IF WORK
OWNER I �N` CONTRACTOR 'Se SIIS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTI N RECORD 180 DAYS OF PERMIT ISSU-
ANCE OR 180 DAYS FROM
LASTCALLED INSPECTION.
UFER
PERMIT VALIDATION
PREGUNITE
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED -
UNDERGROUND /SLAB ,q /
PLUMBING
ELECTRICAL ISSUANCE DATE
BLDG, ELECT. PLG. MECH,
MECHANICAL ❑ ❑ ❑ 0
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
PLUMBING '
WOOD FLOOR VALUATION StFT.
-
- � J
MECHANICAL PERMIT ro
ELECTRICAL c7 tv
FRAMING U
STORIES TYPE CONSTR.
INSULATION
OCC.GROUP RES,UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
50,Fr FLOOR AREA TOTALACREAGE
ROOF
DIAPHRAGM
BUILDING USE
NES IND CON PB O'ne'
I El El 0 El
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED El
ASSESSORS PARCEL NO.
ROUGH
PLUMBING
TRACT NO. PARCEL NO.
` GAS TEST
MECHANICAL ,
ELECTRICAL FINALS DATE INSP. Acc.DnTE Acc.ELLE No.
FRAMING SAN #
ZONING ENG.SITE NO.
INSULATION PLUMBING
GAS
FYo IRE SPRINK ENERGV T39
MECHANICAL N0 y E] No
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
FLOOD ZONE A.LLLC.
LATH—INTERIOR ELECTRICAL
LATH—EXTERIOR FIRE.DEPT. °❑ N� w ❑ N❑
SHEETROCK GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING
1 SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING
FIREWALLS ELECTRIC PLAN CHECK
F —
GAS EE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE -r
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
H ONE WORKING DAY BEFORE REQUIRED INSPECTION.. PLUMBING
0 PLEASE GIVE JOB ADDRESS WHEN PHONING.
Z MECHANICAL
- SEE PERMIT FOR EXPIRATION DATE -
IMPORTANT! 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
BDILORESS DING
AO07f� PAL APPLICATION & PERMIT 11614
{�'ft�-a�
1 01-A
3 Ne IkL 12- BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
��// OwrvER'S �PVvV PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE
I .ON a
CON RACTORs C UTLETS-SWITCHES-RECEP 10.00/1.00
NAME �^ r�/
<1 ES /V�uc.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADDRESS
vHONEPANELS 10.00 DATE OF APPLICATION
ARCHITECT
PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR �
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.On ENG. 5.00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
o0i g �
r 02 LICENSED CONTRACTORS DECLARATION
G u u I hereby affirm that I am licensed under provisions of Chapter'I D ISSUANCE DATE
N <w (commencing with Section 7000)of Division 3 of the Business and BLDG. ¢L'FtGT... 'PLG._ tAECH.
H n z Professions Cc license is in full fu c-' J if' ❑ 'F-'� !LJ
J El
i o m- icenu a s Lic.Number i s.t 7 LJ U
9 y H w Date -a Contract • t{V
E Q w OWNER-BUILDER DECLARA'T'ION - B`INO MAT
MM
X ; N I hereby affirm that I am exert t from the Contractor's License MISC.- LR_VffR ORD
LL Y' p VALUATION $/FT.
u o a Law for the following reason.(See.requires
a,Business and Professions PERMIT ISSUANCE 10.00
� - Code: e,dem y demolish,
coo my whiny structure,
u tune, prior to is isstruct,alter,
uance.
also
5 <Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.N0. TOTAL (/b
O u requires the applicant for such permit to file a signed statement that TOTAL PERMI TO
w$ he is licensed pursuant to the provisions of the Contractor's License
H z i Law(Chapter 9(commencingwith Section 70001of Division 3 ofthe ly
i EE a Business and Professions Code)or that he is exempt therefrom and QTV. PLUMBING PERMIT FEE
c the basis fur the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i ;m by any applicant for apemlit subjects the applicant toacivil penally ALTER-DRAIN&VENT-WATER IEA.) 5.00
of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their Sale 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
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves[hereon,and who does such work IF IXTUR ES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
'eats are oti intehrough nded
own emred for
pe.If.ed however,the
improvo GAS-EA.SYSTEM-I 6,00
mems are not intended or offered for sale.1L however,the building
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 inn- RES IND CON PB Omer
Prove for purpose of sale.). INDUSTRIAL WASTE 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:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.1 1.00
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SAN ITARV-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ I am exempt under Sec..,R&P C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.OATE ACC,FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate ofconsent to self-insure, ZONING ENG.SITE NO.
or certificate of Workers'Cumpel)Sa i r ✓>y r (y,ora certified
copy thereof L6e�00, 1IC.). L 1 7
Policy No. C I y
Q erllfied copy is herebyf ' s - FIRE SPRINK ENERGY T24
Z_ Z sT Certified copy is filed wt the city Ito action ivisi n. MISC.- REFER TO ORD. y❑ N E] y ❑ NE]
F/
Appl' am
N PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
C iR'fIEICATE IiXIiM PT F OM WORKERS'
LU > COMP17NSATION INSURANC17 PLG.CONTE. LIC.NO. PLG.
dO TOiAL Y❑ N❑ Y❑ N❑
(This senior need not be completed if the permit is far one
D Z hundred dollars(S100)or lc..)
U O I certify that in the performance of the work for which this per. QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued,I shall not employ any person in any manner o as to
O W become subject to the Workers'Compensation Laws of California. BUILDING p a
Date Applicant ALTER OR ADD TO MECH. 5.00 a S
} to NOTICE 1'0 APPLICANT': If,alter making fills Certificate of Cx-
♦- Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK a y
provisions of the Labor Code, you must forthwith comply with FEE S �•
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Q000C-F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1O=C.EM.) 6.00 SEISMIC FEE
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. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.l.
Lender's Name - HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC 3 -
Lender's Address
Icertil'y that l 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 BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
�1 ordi ances and state laws relating to building construction, send
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property fur inspection purpuws,
(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 said City in consequence of the
gronlil Of this permit. F CM.CONT. LIC.NO. MECH.
�/ TOTAL TOTAL 7 7 0 i
Signature of Applicant/Contractor Date �T
OFFICE COPY