16111 POST THIS CARD NEAR FRONT OF BUILDING
PERMIT NUMBER
* - CITY OF ` CUPERTINO 16111
INSPECTION DIVISION
u" JOB INSPECTION RECORD
I f
L- EXPIRATION
I
¢ � PEAMITEXPIRATIONON
JOB ADDRESS ro�a3 N • GlOL F>r �J7 UNIT# �Oy2 LOT# -
�4SA A N PERMIT EXPIRES IF WORK
OWNER (i4� CONTRACTORS ` IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT.ISSU-
FOUNDATION - ANCE-OR 180 DAYS FROM
NOTE: .LASTCALLED INSPECTION. .
UFER ALL GRADING AND DRAINAGE SHALL BE INSTALLED
PR EGUNITE - - TO COMPLY WITH THE APPROVED PLANS AND CIN OF PERMIT VALIDATION
CUPERTINO STANDARDS: ``�� rr '
GARAGE SLABS ic1A cc,c 'v
POUR NO CONCRETEUNDERGROUND /SLAB BEEN SIGNED •A� (1.7 /e,'71
1
PLUMBING - 1+
j} 51
ELECTRICAL - ISSUANCE DATE
BLDG 'LECT PLG: MECH.,. '
MECHANICAL - � - � � � '
❑ ❑ ❑PAID
I
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED - BUILDING PERMIT
INFORMATION
WOOD FLOOR r VALUATION $/FT.
PLUMBING - . '
MECHANICAL tCiW ot CupprfiIL1.• i (,'l)V
ELECTRICAL PERMIT To
FRAMING11� II` 1 --II
INSULATIONSTORIES TYPE CONSTR,
• '
• _ OCC.GROUP- RES UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
% - SO.FT FLOOR AREA TOTAL ACREAGE
- ROOF NOTE:NO FINAL INSP.SHALL BE MADE BEFORE,
1
DIAPHRAGM THE CONSTRUCTION TAX IS PAID
ROOF SHEATHING' - _ RES INDDILuCOON USEPBOm.,
APPLY NO ROOFING UNTIL ABOVE'HAS BEEN SIGNED FINALS DATE INSP.
ASSESSORS PARCEL NO
ROUGH SANA I
PLUMBING ELECT.ENERGY.
'TRACT NO PARCEL NO. .
TUBS 8 SHOWER PAN PLUMBING ENERGY
MECHANICAL, MECH.ENERGY
ELECTRICAL - BUILDING ENERGY - ACC DATE: ACC.PILE No,
FRAMING ELECT,FINAL TEST
INSULATION PLUMBING ZONING ENG:SITE NOT
GAS TEST GAS '
MECHANICAL PiRE srnwK ENERGY T..4
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING " NE]
- ELECTRICAL RELEASE FLOOOZONE ALL ULC
' EXTERIOR SHEAR � _
INTERIOR SHEAR - FI RE DEPT. YY �] N❑,
SHEETROCK GRADE - FEE SUMMARY
EXTERIOR LATH BUILDING: 17-777
INTERIOR LATH TEMPORARY APPROVAL BUILDING I^
SCRATCH COAT ELECTRIC- PLAN CHECK
GASFEE itj•(itf,lU •` ,-y G
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE Cl
- OCCUPANCY OF BUILDING IS NOT PERMITTEDUNTIL BUILDING FINAL IS SIGNED BY'BUI LDING INSPECTOR. MICROFILM I
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
F ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
z PLEASE GIVE JOB ADDRESS WHENRHONING.,'
- SEE PERMIT FOR EXPIRATIONDATE - MECHANICAL
IMPORTANT! CONST.TAX
=PLEASE READ REVERSE SIDE BEFORE
CALLING FOR FINAL INSPECTION. TOTAL �L
OFFICE COPY -
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -.USE BALL POINT PEN ONLY
eUl`^ NPROJECT 16ENTI FICATION - - PERMIT NUMBER
auILo1N _ APPLICATION & PERMIT ' 16111
aoo Ea p�
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 4"
t OWNER'S IU - PLAN CHECK VALIDATION
- nacos j� �'De /O CITY. ELECTRIC PERMIT FEE
fV l' qq
5 /_C
MERAcioR'sNAAOUTLETS-SWITCHES-RECEP 10,00/1.00
LIC NO. LIGHTING FIXTURES' 10.00/1.00
CONTRA
ADDRESS "
ciOR's '- APPLIANCES-RESIDENTIAL 4.00
ooREs
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT /O»n (/jOY PANEL'S (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINE L/^
Lgr7OLIC No. SIGNS TRANS. 3.00
AARCH.OR 00RESS ENG. SPECIAL CIRCUIT. - 5.00 PERMIT VALIDATION
�CQ CIrIC/ IPµ� 0 EMP.METER OR POLE INS. 20.00 aL\Tt1r.l1'Y'`nj1
' APPLICANT'S;
AOORE55l7
r2r)iJ Qjs �j C(/VY MOTORS SEE FEE SCH.
J D /J (�lV% 1 /1
SERVICE CHANGE Y-� (J 1
o o LICENSED CONTRACTORS DECLARATION
Q u i- 1 hereby affirm that I am'licenaed under provisions of Chapter 9 ISSUANCE DATE
y "' (commencing with Section 7000)of Division 3 of the Business andMAY
Q BLDG. LECT. PLG. MECH.
F N i Professions Code,and my license is in full force and effect. ❑ ❑ O
z o m - License Class Lia Number _ -
9 z H D Dale Contractor I p,• •n4^
a y E � City ty W BUILDING PERMIT
a w u OWNER-BUILDER DECLARATION - INFORMATION
w,�uy., I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION $/FT.
C, Law for the following reason.(Sec.7031.5,Biaineasand Professions PERMIT ISSUANCE 10.00 t
Code,Any city orcounty'which requires a permit to construct,alter, I(\� (�/�O
1
ac
Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. V, (J(:J
D e, requires the applicant for such permit to file a signed statement that TOTAL + PERMITITO 1
'-w m w he is licensed pursuant to the provisions of the Contractor's License ` ,IYII
rzQ
Law(Chapter 9(commencingwith Section 7000)orDivision 3 caths,
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢F $ the basis for the alleged exemption.Any violation of Section 7031.$ 'STORIES TYPE CONSTR.
by any applicant for i permit subjects the applicant to a civil 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
f 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 or through his own employees,provided that such improve-
hoots are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 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 an- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
po, or purpose ofsald). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omar
I,as owner of the property,am exclusively contracting with 1:1 ❑ ❑ ❑ ❑
1' ens it contractors to construct the project(Sec. 7044,Business - LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
nil 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 u contractor(s)licensed pursuant to l SEWER-SANITARY-STORM EA.200ft/10.00
the Carburetor'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.GATE ACC.FILE N0.
' WORKERS'COMPENSATION DF.CLA RATION. WATER TREATING EQUIP. 5.00 -.
1 hereby affirm that I have a certificate of consent to self-insure,' ZONING
or a'certificate of Workeis'Compensation Insurance,or a certified ENG.SITE NO.
• copy thereof(Sec.3800,Lab.C.). '
Policy No. Company
Q ❑ Certified copy is hereby furnished. FIRE SPRINK. ENERGY T 24
. Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD..
O''. Applicant V.❑ N❑ Y ❑ N❑
= w CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A:L.U.C.
LU COMPENSATION INSURANCE PLG.CONTE. LIC.NO. _ PLG. Y❑ N❑ Y ❑ ry❑
(This section need not be completed if the permit is for one j' TOTAL
hundred dollars 1$100)or less.) -
U O I certify that in the performance of the work for which this per- CITYMECHANICAL PERMIT FEE FEE SUMMARY
LL.,F mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
O i Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING 0057
} m NOTICE TO APPLICANT: If,after making this'Certificate of Fs-
caption,
x-
ca ption,you should become subjectto the Workers'Compensation APPLIANCE 5.00 - PLAN
provisions of the Labor Code, you must forthwith comply,with FEE,
U 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.EM.) 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,Co.CJ. -
Lender'sAddr 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 state that the above VENTILATION FAN (SINGLE) 4.00 "
information d estate l l agree to comply with all city and county PLUMBING
ordininformnces ation
is state laws relating In building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL
above-mentioned_propert r inspection purposes. .
(We)r a to save mile ni and keep harmless the City of MISC.- REFER TO ORD.
upertin again a ities Ij gments, costs and expenses which _ CONST.TAX
ay ny way cc a st said City in consequence of the PERMIT ISSUANCE 10.00
m n of i mit. " F MECH.CONT. LIC.NO. MECH.
v TOTAL TOTAL 77 1 V
gnature of Applicant onhad 1142 1 G e 2
i.
OFFICE COPY