10715 POST THIS CARD NEAR FRONT OF BUILDING
PER%lIr NUMBER
CITY OF CUPERTINO 10775
INSPECTION DIVISION
JOB INSPECTION RECORD'
i•, /PERMIT EXPIRATION
JOB AD RESS�i UNIT LOT#
PERMIT EXPIRES IF WORK
OWNS CONTRACTOR IS NOT STARTED WITHIN
NSPECTION DATE SPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDA ION .LANCE OR 180 DAYS FROM
LAST CALLED INSPECTION.
UFER
PERMIT VALIDATION
PREGUNITE
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB ( LI'
PLUMBING 1 �I '
ELECTRICAL IS Ad DATE
BLDG. El CT. PLG. MEC .
MECHANICAL /
� L
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED ilBUILDING PEReM1T
INFORMATION
WOOD FLOOR tNF,SIFT.
PLUMBING
MECHANICALELECTRICALFRAMINGINSULATION comsTR..UNITSPLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNEDL nCHEFGE'
ROOF
DIAPHRAGM
BUILDING SE
RES IND C N PB Otivn
El 0
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED I
nBBESHOR A CEL NO.
ROUGH
PLUMBING
TRACT NO. PARCEL NO.
GAS TEST
MECHANICAL
ACC. ATE ACG FILE NO.
ELECTRICAL FINALS DATEINSP.
FRAMING SAN #
ZONING ENG.SITE NO.
INSULATION PLUMBING
GAS
FIRE SPRINK ENERGY TSE
MECHANICAL Y ❑ NE] Y ❑ NEI
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
FLOOD ZONE A.LLLC.
LATH—INTERIOR ELECTRICAL
LATH—EXTERIOR FIRE DEPT. v N� v �] N❑
SHEETROCK GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING
FIREWALLS ELECTRIC PLAN CHECK
F
GAS EE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
H ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
j • z PLEASE GIVE JOB ADDRESS WHEN PHONING. MECHANICAL
IMPORTANT!
1 - SEE PERMIT FOR EXPIRATION DATE -
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
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING / APPLICATION & PERMIT
AOa;REss/ DV0 0t'F� BUILDING—ELECTRICAL—PLUMBING—MECHANICAL 10715
1 OWNER'S U q�_,p�U PLAN CHECK VALIDAT},ON
r < "AMEe-wL � L Z3� QTY. ELECTRIC PERMIT FEE
HONE //
coNTRAcrCR'sUTLETS-SWITCHES-REQEP 10.00/1.00 S 9
NAME
LIC.No. vLIGHTING FIXTURES 10.00/1.00 p
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADORSSS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT /� / �f�' `/ (o PANELS (OVER 200 AMPI 20,00 Q PLAN CHECK FEE P.C.NO.
OR �(i W/ef/ CIC.Na.
ENGINEER � SIGNS TRANS. 3.00
ARCH.OR ENG. 6.00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
ZIP EMP.METER OR POLE INS. :00 PAI
APPLICANTS IMOTORS 3 HD FEMFFESCH.
ADDRESS
SERVICE CHANGE I 20. � I'J +• !/_�.yg J
F o o LICENSED CON'T'RACTORS DECLARATION
a u v I hereby affirm that 1 am licensed under provisions of Chapter 9 ISS E TE
N <N (commencing with Section 7000)of Division 3 of the Business and BL G. EL P
H w z Professions Code,and my license is in full force and effect.
z ° License Class Lie.Number
° zra° Da[c Contractor
a Y f BUILDING PERMIT
¢ ¢ w OWNER-BUILDER DECLARATION INFORMATION
w , w I hereby affirm that 1 am exempt Iron.the Contractors License MISC.— REFER TO ORD
uoa Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
t - Code:Any city or county which requiresa permit to construct.alter, �'� 4-(�
Qso Q 2O Improve,demolish,or repair any Structure,prior to Its Issuance,also ELEC.CONTE. LIC.NO. ELEC.
° ¢ requires the applicant for such permit to file a signed statement that TOTAL g�Q Q ' PERMIT TO
a w es" he is licensed pursuant to the provisions ol'the Contractor's License yt��
Hzi
Law(Chapter 9(commencing with Section 7000)ofDivislon 3 oflhe �n/7CRlUiQ /ALS/-ad
at Business and Professions Code)or that he isexempt therefrom and OTV. PLUMBING PERMIT FEE
f z OSTORIES TYPE CONSTR.
¢ H o the basis for the alleged exemption.Any violation of Section 7031.5
ate _ by any applicant lora permit subjects the a pplic,olt.acivilpenalty ALTER
-DRAIN&VENT-WATER (EAJ 5.00CIO
of not more than five hundred dollars(5500))'.
❑ 1,as owner of the property,or my employees with wages as IBACK F LOW PROTECT. DEVICE 4.00 Dec.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
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOfl AREA TOTAL ACREAGE
himself orthrough his own employees.provided that such improve-
ments11 arc 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.) F2. BUILDING SE
builder will have the burden of proving that he did not build or im- RES IND PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 0;00
❑ I,as owner of the property,am exclusively contracting with - - ❑ El El El
licensed contractors to construct the project(See 7044,Business LAWN SPRINKLERS-1 NCS V. Ed6,00 J`aW AS50 PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or in.provcs thereon,and who LAWN SPRINKLERS-OVER 5(EA,) 1.00
contracts r such projects s lh a contradugs)licensed pursuant to SEWER-SANITARY-STORM EA.2 / •I TRACT N0. PARCEL NO.
the Cont for's License L.
❑ I exemP�under. c�_.B.&P.C.for this WATER HEATER W/VENT 6.00
reason _
Own _ Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
I hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.CJ.
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z C1 Certified Copy is Filed with Ore City inspection division. MISC- REFER TO ORD. v No v N�
FyApplicant
PERMIT ISSUANCE 10.00 O FLOOD ZONE A.L.u.C.
CC > CERTIFICATE OF EXEMPTION FROM WORKERS'
W COMPENSATION INSURANCE PLG.CONTE. LIC.NO. "PLG �(This section need not be completed if the permit is for one Y C] N� Y❑ NZ hundred dollars(S 100)or less.)
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIFEE FEE SUMMARY
mil is issued,I shall not employ any person in any manner so as to
LL become subject to the Worked Compensation laws of California. O BUILDING Zj
Date Applicant ALTER OR ADD TO MECH. 5.00
} rap 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 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 10p000.F.M.) 6.00 ° - SEISMIC FEE S
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, .W.) 6.00 MICROFILM
3097,0,C). -
Lender's Name H EATI NG U N IT(OV E R1 vv,uuu 13.T.U.)9.50 ELECTRIC �_ O
Lender's Address
1 certify that I have read this application and state that the above VENTILATION FAN ISN LE{ l!-r 4;00
�., PLUMBING
information is correct. I agree to Comply with all city and county
ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.oT 10 ,000 B.T.U.1 6.00
hereby authoroC representatives of this city to enter upon the BOILER-COMP (DVBI 1000 OBT 13ki:CH. MECHANICAL �'
above-mentioned property for inspection purposes.
(We) agree In save, indemnify and keep harmless the City of MISC.- RTO ORD.
Cupertino against liabilities,I. figments, costs and expenses which PERMIT ISSUANCE 10.00 O CONST.TAX
\ may in way ac rue ag s 'id City in crosequence of the
granting this per L MECH.CONT. LIC.NO. MECH.
TOTAL 33 o-o TOTAL
Si ure of Applicant/ lmdor Date /
OFFICE COPY ,