11617 POST THIS CARD NEAR FRONT OF BUILDING
PERMIT NUMBER
CITY OF CUPERTINO 11617
ti INSPECTION DIVISION
JOB INSPECTION RECORD
JOB ADDRESS_!� -�� k)OI'fCl Ed PERMIT EXPIRATION
U�/> j/{�. O / PERMIT EXPIRES IF WORK
OWNER I-{' -IJ I / I(/ CONTRACTOR S `Q IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 160 DAYS OF PERMIT ISSU-
ANCE OR 180 DAYS FROM
LASTCALLED INSPECTION.
UFER
PERMIT VALIDATION
PREGUNITE
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED j
UNDERGROUND /SLAB
' PLUMBING h�•
ELECTRICAL ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
MECHANICAL El El !] ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERM
rr
INFORMATION
WOOD FLOOR
VALUATION $/FT.
PLUMBING - V
MECHANICAL vEHMIT To
ELECTRICAL
S i6N`
FRAMING
STORIES TYPE CONSTR.
INSULATION
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
50,IT,F1.00H AREA TOTAL ACREAGE
ROOF
DIAPHRAGM
RUILOI USE
• H[$ IND CON
PB Omm
0 0 13
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED EL
ASS ESSOH$PARC EL NO,
ROUGH
PLUMBING
TRACT NO. PARCEL NO
GAS TEST
MECHANICAL
ACC.DATE ACG FILE NO.
ELECTRICAL FINALS DATE INSP.
FRAMING SAN *
ZONING ENG,SITE NO.
INSULATION PLUMBING
GAS
FIRE SPRINK ENERGY T24
MECHANICAL Y [-] N❑ Y 1:1 NEl
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
FLOOD ZONE A.LU C.
LATH-INTERIOR ELECTRICAL
LATH-EXTERIOR FIRE DEPT. v N� v �] N❑
SHEETROCK GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS
FIREWALLS ELECTRIC PLAFEE CHECK
GAS
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
. LLI ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
0� PLEASE GIVE JOB ADDRESS WHEN.PHONING.
Z MECHANICAL
— SEE PERMIT FOR EXPIRATION DATE —
h IMPORTANT! CONST.TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL d
CALLING FOR FINAL INSPECTION.
I, OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 11617
ADDRESS
.� I G-ELECTRICAL-PLUMBING-MECHANICAL
OWNER' ryp�y�� PLAN CHECK VALIDATION
• NAME C'Jp QTY. ELECTRIC PERMIT FEE
I.ONE:17 141
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
NP
i uc.No. LIGHTING FIXTURES 10.00/1.00
CONT JTO SA/Cs� PPLIANCES-RESIDENTIAL 4.00
Aftl;__ �5/J7
ROrvE PANELS 10,00 DATE OF APPLICATION
ARCHITECT aill PANELS (OVER 200 AMP) 20.00 PLAN CHELK FEE P.C.NO.
O
EhL LIGMta! SIGNS TRANS. 3.00
ARCH.OR ENG. 5.00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
Woo LICENSED CONTRACTORS DECLARATION /�
Q u w 1 hereby Strom that I am licensed under provisions of Chapter 9 AID ISSUANCE DATE
<w (commencing with Se fi 000)of Division 3 of the usi s and BLDG. ELECT. PLG. MECH.
F N z Professions Co �) icenre is in full foleCT ❑
2 o m - License Class )) 11 Lic,Number .��GG iii !!l wv p 1 1 '1J 1"{J ❑
Q o Datc CuntrautuZQ FI V
a y //tA JJ BUILDING PERMIT
2 a w OWNI'RBUILUER DECLARATION RMATION
REFER TO ORD n P.
wu y I hereby affirm that I am exempt from the Contractor's License MISC.- VALUATION SIFT.
LLO ¢ Law for the following reason(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 •] )
as Code:Any city or county which requires a permit to construct,alter,
2 Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. �J
O IC requires the applicant for Such permit to file a signed statement that TOTAL pE�'V TO
d w m" he is licensed pursuant to the provisions of the Contractor's License
H t i
Law(Chapter 9(commencing with Section 7000)ofDivision the
¢ Business and Professions Code)or that he is exempt therefrom and CITY PLUMBING PERMIT F E
¢ ° the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n ; $ by any applicant lixapermit subjects the applicant oacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).1:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT,DEVICE 4 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,AR EA,COND. .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 so.Fr.PLooR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsare not intended oroffered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUT TS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 1 A.) 2.00 BUILDING USE
In.
will have the burden of proving that he did not build or im- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIALWASTE INTE 30.00
0 I,as owner ol'tile property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 1)(C 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Luw does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKL S- VER 5(EA.) 1.00
contracts for such projects with a contractorls)licensed pursuant to
the Contractor's License Law. SEWER-SANITA -S RM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sea ,B.&P.C.for this WATER HEATS NT 6.00
m'0n
Owner Date WATERSYST 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TR ATING EQUIP. 5.00
I hereby affirm that I have a certificate ofcousent to self-insure, ZONING ENG.SITE NO.
or a certificate of W Compensation Insurance,or a cert ed
ropy it 1, Ah.C.).�IJ�9�fBLIC/WD
Policy N0._ ompany-
O ❑ Cent a -o'6hereby furnished FIRE SPRINK ENERGY Tg4
Z 2 0 Certified copy is riled with the city inspection division. C - REFER TO ORO. Y❑ N❑ Y ❑ N❑
yApplicant
ERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
- CERTIFICA'I'17 OF EXFMPI'ION FROM WORKS RS'
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N E] Y ❑ NF]O ('Phis section need not be completed if the permit is for one TOTAL
0 Z hundred dollari(SI00)or less.)
U O I certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT EE FEE SUMMARY
UL I- mil is issued, I shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws of California. BUILDING q
Date Applicant ALTER OR ADD TO MECH. 0 3a
} t6i) NOTICE TO APPLICANT: it,after making this Certificate of Ex-
�. ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK r) �D 2
provisions of the Labor Code, you must forthwith comply with FEE �J
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000CF ) 4.00
CONS rRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10 .F.M.) 6.00 SEISMIC FEE 0.-D
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WIIH D T) 5.00
lire performance of the work for which this permit i cd(Sec. MICROFILM
3097,Cie.C.). HEATING UNIT IT 00 B.T.U.) 8.00
Lender,Name_ HEATING UNIT IO R0,000 B.T.U.)9.50 ELECTRIC
Lender's Address
. I certify Iflat I have read this application and state that the above VENTILATION 4N ( GLE) 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-COMP H.P.or 100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-C P(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for inspection purposes.
(We) a t save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertin or t liabilities,ju Is, costs and ex nse'which CONST.TAX
may in ny Sy accrue ag t d City i copse enc of the PE IT ISSUANCE 10.00
goo is -omit MECH.C T. LIC.N0. MECH. '-
TOT"` TOTAL 6
Sign of ma C r )at
OFFICE COPY