14253 POST THIS CARD NEAR FRONT OF BUILDING
CITY OF CUPERTINOPERMITNUMBER
'
• � 14253
INSPECTION DIVISION
• JOB INSPECTION RECORD
PERMIT EXPIRATION
JOB ADDRESS .10123 -N WOLFE ROAD UNIT# LOT#
PERMIT EXPIRES IF WORK
OWNER BUSTERS BAR &GRILTuONTRACTOR IS. NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION ANCE OR 180 DAYS'FROM
LIFER
LASTCALLED INSPECTION.
PREGUNITE PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED N
UNDERGROUND /SLAB
PLUMBING
ELECTRICAL ISSUANCE DATE
MECHANICAL BLDG. ELECT. PLG. MECH.
❑ ❑',
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
WOOD FLOOR INFORMATION
VALUATION S/FT.
PLUMBING -
MECHANICAL
PERMIT TO/
ELECTRICAL - I r. -7,.,.
FRAMING
sroRlEs TYPE CONSTR.
INSULATION
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
• ROOF SO.FT.FLOOR AREA TOTAL ACREAGE
DIAPHRAGM
BUILDING USE
'
RES IND CON PB Other
APPLY,NO ROOFING UNTIL ABOVE HAS BEEN SIGNED j*10 ❑ ❑ ❑ ❑ ❑
ASSESSORS PARCEL NO.
ROUGH 1
PLUMBING 1'r' TRACT No, PARCEL NO;
GAS TEST
MECHANICAL Dt CUPe p0
ACC DATE ACC.FILE NO,
ELECTRICAL FINALS DATE INSP.
FRAMING SAN #
INSULATION - zowNc ENG.SITE NO.
PLUMBING
GAS
MECHANICAL FIRE SPRINK EY E] n 24 N
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING g 8 ° ❑ "❑ ❑ ❑
LATH—INTERIOR ELECTRICAL FLOOD zorvE A.L.0 c.
LATH—EXTERIOR FIRE DEPT. ' v❑ -"❑ Y❑ N❑
SHEETROCK. GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING -
FIREWALLS ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE AEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNEDBY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
0� ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
T
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
• • BU11.DI NG PROJECT IDENTIFICATION PERMIT NUMBER
JILDING APPLICATION & PERMIT
ADDRESS I/� f!J 1,- .� 1 ,4253/I 2 5 3
F/ 1/7 w"Ql.. �t1/ BUILDING -ELECTRICAL-PLUMBING-MECHANICAL /-II'G 3
OppW��y�NE"""R'S PLAN CHECK VALIDATION
• NpM_ - ✓1l/ I L1 OTY. ELECTRIC PERMIT FEE
CON
I ITACTOR S
NA����,�//JJ (��/'up 4502OUTLETS-SWITCHES-RECEP 10.00/1.00
VVMW S'•- LIC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR R'�/}J��(./.( PPLIANCES-RESIDENTIAL 4.00
PRONE V ✓Y- \ PANELS 10.00 DATE OF APPLICATION
ARCHITECTPLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
Llc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS _ SPECIAL CIRCUIT 5.00 '
- ZIP TEMP.METER OR POLE INS. 20.00
1 noo leA"Ts ...I't7! MOTORS SEE FEE SCH. -jK
P.
✓'�' SERVICE CHANGE 20.00 `
w o'o LICENSED CONTRACTORS DECLARATION / 7
v I hereby affirm that I am licensed under provisions of Chapter 9
i ISSUANCE DATE
Z, (commencing with Section 7000)Of Division of B sines and BLDG. ELECT. PLG. MECH.
r H i Professions Cod a license is in full for ❑ ❑ ❑
o i w o License Class Lie,Number
H u F J Dale Contractor
w.a - OWNER-BUILDER DECLARATION
BUILDING PERMIT
wo a o - INFORMATION
3:,R I hereby affirm that I am exempt from the Contractor's License MISC.- _ REFER TO ORD
so Law for the following reason.(Sec.7031.5,Business and Professions - VALUATION $/FT.
u,w< - PERMIT ISSUANCE 10.00
s Code:Any city or county which requires permit to construct,alter,
Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR, LIC.NO.
c rt requires the applicant for such permitTOTA
,to file a signed statement that - L
e.
w2 he is licensed pursuant to the provisions of the Contrite tot's LicensePERMIT TO
FZQ Law(Chapter 9(commencing with Section 7000)of 0 ivision 3 of the ,( __C/
�'E D Business and Professions Code)Or that he isexempt therefrom and QTY. PLUMBING PERMIT FEE /`/
F$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3� by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
Of not more than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 ,
their sole compensation,will do Ole work,and the structure is not DCC.GROUP Res.uNlrs
intended or offered for Sale(Sec. 7044, and
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.FLOUR AREA TOTAL ACREAGE
himself Or through his own employees,provided that such improve-
mentsarenot intended or offered for Sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB other
❑ I,as owner of the property,am exclusively contracting with - ❑ ❑ 1:1 ❑ ❑
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 dues 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 contmetons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA,20011/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sea ,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ' ACC.FILE NO.
WORKF-RS'COMPENSATION DECLARA'T'ION WATER TREATING EQUIP, 5.00
1 hereby affirm that 1 have a certificate of consent to self-insom,
or a certificate of Workers'Compensation I sumnec,or a certified ZONING ENO.SITE NO.
copy]jf��{sqj� Lab.C.), t,la y A4P/
Poli CertlL�mreb y�`• ` 1�1J{"�
Q ❑ Certified capyi hereby furnished FIRE SPRINK ENERGY T�Y4 '
Z Z Certified py Is hl hh the city inspection division.
� 6 sCppli Cc' E py /1es�r MISC.- REFER TO ORD. Y� N� Y ❑ rv�
C W CERTIF CATF.OF Ii1XE_MPTTION FROM WORKERS' PERMIT ISSUANCE
10.00 FLOOD ZONE A.L.U.C.
EU COMPENSATION INSURANCE. PLG.CONTE, UG.NO., PLG.
0. O (This section peed not be completed if the permit is for one TOTAL Y N Y [1] N
D Z hundred dollars($100)or less.) `
U O 1 certify that in the performance of the work for which this per, QTY. MECHANICALrPERMIT FEE FEE SUMMARY
IL F mit is issued,I shall not employ any person in any manner so as to r .
O Wbecome subject to the Workers'Compensation Laws of California.
y Date ApplicantALTER OR ADD TO MEC 5.00 BUILDING
>_ 00 NOTICE TO APPLICANT: If,after making this Certificate of Ex-
t 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
C..1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MOC.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[he work for ich this perm't is issued(Sec. MICROFILM
3097,Civ.C.). �tvfnHEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name 1•�I� '`• -_'
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)6.50 ELECTRIC
Icertify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 56 �-
information is correct. 1 agree to comply with all city and county BOILER- H.P. r 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of
[hpurposes.is city l0 enter upon the BOI LER-COMP(Over $CH.
100,000 BTU)SEE FEE MECHANICAL
above-mentioned property forinspectionh _
(We) agree to save, hAdemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT'ISSUANCE 10.00 O ' CONST.TAX
may any way accrue against said C -in c lsequence of the
gran of
of this p L it- MECH.CONT, LIC.NO. MECH, /�•(/11
TOTAL TOTAL
Signa are of Applicant/ ntrucfor Dalre
OFFICE COPY