12169 POST THIS CARD NEAR FRONT OF BUILDING
PfRMIT NUMBER
CITY OF CUPERTINO 12169
INSPECTION DIVISION
JOB INSPECTION RECORD
`/ s��•IUY��i PERMIT EXPIRATION
JOBADDRESS Z61a23 Nr 1017I_-F.- 2/) UNIT# LOT#
PERMIT EXPIRES IF WORK
OWNER .N'� cS'C./� CONTRACTOR [- (2y 'o IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION ANCE OR 180 DAYS FROM
'LASTCALLED INSPECTION.
UFER
PREGUNITE - PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED �-
UNDERGRQUND /SLAB
PLUMBING
ELECTRICAL ISSUANCE DATE
' MECHANICAL BLDG. ELECT, PLG. MECH.
o El 1:1 O-
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
WOOD FLOOR INFORMATION
VALUATION SIFT.
PLUMBING -
MECHANICAL
ELECTRICAL
FRAMING
STORIES TYPE CONSTR.
INSULATION '
OCC.GHOU RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF -SOFT FLOOR AREATOTAL ACREAGE
DIAPHRAGM
6u1l DING USE
RES IND CON PR 0111e1
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED pw O 0 El E:l 1:1
ROUGH ' T C ASSESSORS PARCEL NO
PLUMBING b�
µ�I .k CT NO. PARCEL NO.
GAS TEST
MECHANICAL V'
ACC DATE ACC FILE NO.
ELECTRICAL FINALS DATE INSP. _ e1
FRAMING SAN # ZONING ENG.SITE NO.
INSULATION PLUMBING
GAS
FIRE SPRINK ENERGY.T 24
- MECHANICAL
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
FLOOD ZONE A.L.U.C.
LATH-INTERIOR " ELECTRICAL Y [-] N� Y 0 N13LATH-EXTERIOR FIRE DEPT.
- SHEETROCK GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING
SHEAR EXTERIOR" TEMPORARY APPROVALS BUILDING
FIREWALLS ELECTRIC PLAN CHECK,.
GAS FEE VV
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINALISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252.4505, ELECTRIC
I� F ONE WORKING.DAY BEFORE REQUIRED INSPECTION. PLUMBING
z PLEASE GIVE JOB ADDRESS WHEN PHONING:
— SEE PERMIT FOR EXPIRATION DATE — MECHANICAL Od
CONST.TAX
IMPORTANT!
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
BNILOING APPLICATION & PERMIT 12169
ADDRESS
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
10123 N W01 fa RC] 41 n1on
OWNER'S PLAN CHECK VALIDATION
NrrAMME� QTY. ELECTRIC PERMIT FEE
The Science Sh -PHONE
CONTRACTOR'S UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
Cal-Air Condition' .NO. 137195 ILIGHTING FIXTURES 10.00/1.00
CONTRACTOR'SAPPLIANCES-RESIDENTIAL 4.00
TDDREss p -I p r�T
1775 lj't St. JU PHONE 947-0155 JPANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER '
l LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT S.QQ PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00 /n �/ �
�
PLICANTS MOTORS SEE FEE SCH,
ADDRESS aYF
1775 S. 1st St. Bldq., 66 Sail JosE SERVICE CHANGE 20.00 1 '? /f
0 0 o LICENSED CONTRACTORS DECLARATION
¢U U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
vHi a i (commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLG. MECH.
H m i Professions Code d.Byf Ilcense Is In full force 1 r A5
z o w- LicensaL sS5 6V Lia Number 7 ❑ ❑ ❑ P,
Dale / L Contractor Q_
a YBUILDING PERMIT
Ie rc w¢ OWNER-BUILDER DECLARATION INFORMATION
a`-'
N ere
I hereby affirm that I am exempt from the ContractoMISC.- REFER TO ORD
r's License VALUATION $/FT.
v a. o J Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requirese permit to construct,alter,
2 ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. '
D I[ requires the applicant for such permit to file a signed statement that TOTAL PERMIT
a w m he is licensed pursuant to the provisions of the Contractor's License ,�A
H z t Law(Chapter 9(commenciagwith Section 7000)of Division 3 ofthe
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ f $ the basis for the alleged exemption,Any violation of Section 7031.5 STORIES TYPE CONSTR.
i by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK F LOW 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 Contractors 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 or through]its own employees,provided that such improve- GAS-EA.SVSTEM-11NC.40UTLETS 6.00
ments are not intended or offered for sale.If,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 im- RES IND CON PB Oshe,
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 6 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.) 1.00
contracts for such projects with a contractons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
I� ❑ lam exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM- 5.00 Ace.DATE ACC.FILE NO.
�s WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a celnsation of a ance,o self-insure, - ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,to a cenlfierl
CP
thereofkSec.3800,Lab,C.I ;}1PV`fy
ry Policy No. Company MLJtElal-
\�Q ppli^.❑ Certified copy ishereby furnished. F ESPRINK ENERGY T24
Cerfif ix file/l�jwl0 11 city Ips echo division.
� 0 A _• �r 7C/U -�a 1 MISC.- REFER TO ORD. 12� N❑ Y ❑ NE]
~ H PERMIT ISSUANCE 10.00 FLOOg ZONE A.L.U.C.
LU ] CERTIFICATE OM EXEMPTION FROM WORKERS' III
W _ COMPENSATION INSURANCE. PLG.cONTR. LIC:No. PLc. Jq�4`i N❑ Y E] N❑
C' D (This section need not be wmOTAL pleted if the Permit is for one TY LJ
D Z hundred dollms(SI00)orlcssJ
V O I certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT C� E FEE SUMMARY
LL P mit is issued,1'shall not employ any person in any manner so as to
U becol srdtl y� a Workers'c�mly.ns.ulan La of C'Ijl rgia.
Ow Date- �Avplicant_1:a1-F�r �'nnr'�T gT nn BUILDING
a ALTER OR ADD TO MECH. 5.00
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex- -
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
CJ 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 I0,000C.F.M.) 6.00 SEISMIC FEE
I 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.).
Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
• I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00 d?0�
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL Qa�
above-mentioned property for inspection purposes.
(W agree to save, indemnify and keep harmless the City of misc.- - REFER TO ORD.
C e i against linbilitie 'udgmen s, costs and expenses whame�
CONST.TAX
ma any w11y accrue a 'nM Sri City consequence o
t i NO. 2-
OFFICE
.�a TOTAL
Sign ureofApplican/Contractor ate
COPY