12082 POST THIS CARD NEAR FRONT OF BUILDING
CITY' OF CUPERTINO RMITNUn"BER
INSPECTION DIVISION
12082
. JOB INSPECTION RECORD
PERMIT,EXPIRATION /
JOB ADDRESSVV IN NV UNI T# 'A _LOT# _
PERMIT'EXPIRES IF WORK
OWNER CONTRACTOR , IS NOT STARTED W1ITHIN
INSPECTION DATE INSPECTOR INSPECTION RE ORD 180'DAVS OF PERMIT ISSU-.
FOUNDATION' - ANCE OR 180 DAYS FROM
UFER _ - • _ LASTCACLED INSPECTION.
'PREGUNITE _ PERMITVALBDATION ,
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB
PLUMBING -
ELECTRICAL - - "
ISSUANCE DATE'
'MECHANICAL - a, PLa. MECH,
R_ K ❑ .
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED uR DINc PERMIT
WOOD FLOOR - ., INFORMATION
PLUMBING
•VALUATION .$/FT,
MECHANICAL . -
ELECTRICAL - - PERM
FRAMING AfM
-
INSULATION - ,' STORIES TYPE CONSTR.
OCC.GROUP .RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOFSO.FT,FLOOR AREA TOTAL ACREAGE
''r� '�- DIAPHRAGM .• � ,
BUILDING USE
_ RES IND CON PB , Other
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑ ❑ - ❑
ROUGH
ASSESSORS PARCEL NO,
' '
PLUMBING -
GAS TEST: - - - TRACT NO. PARCEL NO,
MECHANICAL
ELECTRICAL. - - FINALS DATE INSP, ncc,GATE ACC.FILE No..
FRAMING; ' SAN # -
INSULATIONPLUMBING ZONING ENG.SITE NO.
- GAS 1
MECHANICAL FIRE SPRINK ENERGY T.24
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING ❑ , N❑ ❑ N❑
LATH-INTERIOR - - ELECTRICAL ELOODZONE A,L.U.C.
LATH-EXTERIOR' - FIRE DEPT Y❑ N❑ Y ❑ N❑
SHEETROCK - 4 GRADE _ -
FEE SUMMARY I
SHEAR INTERIOR BUILDING'
SHEAR EXTERIOR ------APPROVAL BUILDING_ --
- FIREWALLS. , ELECTRIC PLAN CHECK
GAS - FEE 1;
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE P '-
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILD ING FINAL IS SIGNED BY BUILDING INSPECTOR. M ICROFILM
' ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC 4
o� ONEWORKING DAY BEFORE, REQUIRED INSPECTION. PLUMBING PLEASE GIVE JOB ADDRESS WHEN PHONING.
MECHANICAL,
CONST.
' — SEE PERMIT FOR EXPIRATION DATE —
IMPORTANT! coNST.TAX
PLEASE READ,REVERSE'SIDE BEFORE
CALLING FOR FINAL,INSPECTION.
�* TOTAL.
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING ISG PRES26¢7 �� APPLICATION & PERMIT
B /2s tum BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 12082 On
"t�,C OWNER'5PLAN CHECK VALIDATION
MC--L- wA �rft- A a
\ "A` 5�� CITY. ELECTRIC PERMIT FEE
OrvE
NAM TO 'S
E� �R
/
NAM ��t/r. OUTLETS-SWITCHES-RECEP 10.00/1.00 0
-� LIC.NO.SO07 LIGHTING FIXTURES 10.00/1.00 t1
CONTRACTORS O Bpy 1Z9`97 APPLIANCES-RESIDENTIAL 4.00
z,,f.A e4- e ^ 7,0 PHONE - PANELS 10.00 DATE OF APPLICATION
ITEci' ' PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
GINEER
SIGNS TRANS, 3.00
ARCH.OR ENG. PERMIT VALIDATION
aoOREss P.o,B�K �O7 SPECIAL CIRCUIT 5.00
6L.C�V ZIP EMP.METER OR POLE INS. 20.00 j
r ~
AvvucaNrs �
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 / .y// /
w o o LICENSED CONTRACTORS DECLARATION '
¢u I hereby affirm that I am licensed under provisions of Chapter 9 - I r•' ISSUANCE DATE
I- a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r w i Professions Code.' d my license is N full for'•and I - ❑ ❑
z O m Lice lass Lic.Number -
o - o Date Contractor s
a u f BUILDING PERMIT
¢ ¢o u D OWNER-BUILDER DECLARATION _ INFORMATION
w3 w I- 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
H,L 0 s� Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
-' Code:Any city or county which requiresa permit toconstruct,alreq Q ��D
¢ u,<p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. (�
O¢ requires the applicant for such permit to file a signed statement that TOTAL Q / pEIT TO
u w$ he is licensed pursuant to the provisions of the Contractor's License /v7
Hii Low(Chapter 9(commencingwith Section 7000)of Division 3 ofthe E'7�/D�CL_
f 4 o Business and Professions Code)or that he is exempt therefrom and QTY- PLUMBING PERMIT FEE
at F$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a$ - by any applicant for a permit subjects the applicant-toacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ 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
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..FT.FLOOR AREA TOTAL ACREAGE
himself of Through his own employees,provided that suchimprove-
•s meals are nut intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
SE improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). I
INDUSTRIAL WASTE INTER3000 RES IND CON PB Other
. .
❑ I,as owner of the properly,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 IEA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsent to self-insure' ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(See.3800,Lab.C. -
Policy No. Company /9 S is
❑ CCrtlf copy¢hereby furnished. FIRE SPRINK ENERGY T-24
Z Z r1f Cert'led copy is !'y,� i.'cI' Oso city inspection division.
Applicant�2_ ..�.a MISC.- REFER TO ORD. Y ❑ N❑ v ❑ N❑
2 - CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG,CONTR. LIC.NO. PLG.
CL D (This section need not be completed if the permit,Is for one TOTAL Y❑ N❑ Y❑ N❑
D Z hundred dollars(S 10()or t,Ss,)
U O 1 certify that in the performance of the work for which this per-. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
1L 1- mit is issued,I shall not employ any person in any manner so as to
iJ become subject to the Workeri Compensation Laws of California. a
0 y Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING /� S
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Cade, you must forthwith comply with FEE
C.) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE esLO
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
Ole 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
Lender's Address HEATING UN IT(OV E R 100,000 B.T.U.)9.500
_ ELECTRIC
(� I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-CQMP(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)SEE FEE SCH. MECHANICAL
v
e agree to save, ind nify and keep harmless the City of MISC.- REFER TO ORD,
uperti o against lisbilitie dgmenti, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may any way accrue a nst said City in consequence of the
grand of thisp it. - MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
afore Applicant/Co actor Date
OFFICE COPY