11051 POST THIS CARD NEAR FRONT OF BUILDING
Pf TIM IT NUMBEH
CITY OF CUPERTIN04& 11051
INSPECTION DIVISIONJ�
` JOB INSPECTION RECORD
�]� •�/I 1 / 1�/) � PERMIT EXPIRATION
JOB ADDRES /II/!' /V) IV( IVA1J/`/U'�Ili UNIT _LOT#
PERMIT EXPIRES IF WORK
OWNER CONTRACTOR IS NOT STARTED WITHIN
INSPECTION DATE I INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
ANCE OR 180 DAYS FROM
LAST CALLED INSPECTION.
UFER
PERMIT VALIDATION
PREGUNITE
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB ( �a
PLUMBING '
ELECTRICAL ISSUANCE DATE
MECHANICAL BSL-O�9 ELECT. PLG. MECH.
J\ El ❑ ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR VALUATION SIFT.
PLUMBING ,.
MECHANICAL
• P`RMII TO �,
ELECTRICAL
FRAMING fII
STORIES TYPE CONSTR.
INSULATION
_ OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BE SIGNED
i SO.FT.FLOOR AREA TOTAL ACREAGE
ROOF
DIAPHRAGM
BUILDING USE
HES IND CON PB Olnr•
0 0 El El
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED E)ASSESSOR SPARC EL NO.
ROUGH
PLUMBING
TRACT NO. PARCLI NO.
GAS TEST
MECHANICAL
' ACC.DATE ACC FILE NO.
ELECTRICAL FINALS DATE INSP.
FRAMING SAN #
20NING ENG.SITE NO.
INSULATION PLUMBING
GAS
FIRE SPRINK ENERGY T 2
MECHANICAL Y ❑ N[:] Y ❑ NF]
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
FLOOD-ZONE A,L.0 L.
LATH-INTERIOR ELECTRIC
LATH-EXTERIOR FIRE DEP `'[-] N� Y ❑ N❑
SHEETROCK GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING j •'!., '�
FIREWALLS ELECTRIC PLAN CHECK
FEE I
GAS
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE f
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
IJ ONE WORKING DAY BEFORE REQUIRED INSPECTION.
PLUMBING
.J
lo
� PLEASE GIVE JOB ADDRESS WHEN PHONING.
Z - SEE PERMIT FOR EXPIRATION DATE - MECHANICAL
CONST.TAX
IMPORTANT!
PLEASE READ REVERSE SIDE BEFORE TOTAL i
CALLING FOR FINAL INSPECTION. --
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDANG PROJECT I DENTI FICATION PERMIT NUMBER
BOILOING APPLICATION & PERMIT
S
O BUILDING-ELECTRICAL-PLUMBING -MECHANICAL 11051
OWNERS C
PLAN CHECK VALIDATION
0�+13r�d'` X57 QTY. ELECTRIC PERMIT FEE
1 V�L vNorvEI�GJ/� 000
/ THACTORsA72 I UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
r.O T CTOR APPLIANCES-RESIDENTIAL 4.00
AOO as
pM Iv1 PANELS 10.00 DATE OF APPLICATION
AR H TECT PANELS (OVER 200 AMP) 20,00
EN WEER PLAN CHECK FEE P.C.NO.
OR
LIC.NO. SIGNS TRANS. 3.00
ARCH,OR ENG. S.00 PERMIT VALIDATION
ADDRESS JEMP.
L CIRCUIT
ZIP METER OR POLE INS. 20.00ADMASS rs RS SEE FEE SCH.
ADDRESS CE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION
a v U 1 hereby affirm that I am licensed under provisions of Chapter 9 T CE DATE
w¢w (¢omnrencing with Section 7000)of Division 3 of the Business and I ELT. PLG. MECH.
F H z Professions Code,and my license is in full force and effect. ❑ ❑ ❑
a, o w - License Class Lic.Number
o o Date Contractor
a r E BUILDING PERMIT
rc w OWNER-BUILDER DECLARATION INFORMATION
w3 u w I hereby ufl'inn that 1 am exempt from the Contractor's License MISC.r REFER TO ORD
H u o j Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
in Code:Any city or county which requires permit to construct,alter,
QQQ� improve,demolish,Ul repair any 5llnelnrC,prior to its l55nant¢,aISO ELEC CONTR. LIC.NO, ELEC. V
O¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
A w m" he is licensed pursuant to the provisions of the Contractors License //VT$�/d R / EM ei C`
Law(Chapter 9(commencing with Section 7000)ol'Dlvision3ofthe V/�
4 o Business and professions Code)or that Im is exempt therefrom and QTY. PLUMBING PERMIT FEE M
s_a the basis for the alleged exemption.Any violation of Section 7031.$ DRIES TYPE CONST .
A. by any applicant for a permit subjects the applicant ton civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).1'.
0 1,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 (Sea 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 docs such work FIXTURES-PER TRAP 5.00 5°.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SV$TEM-11NC.40UTLETS 6.00
mvrts are not intended or offered for sale,ll',however,tire 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 door he did not build or im- RES IND CON PB Door
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with C] ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
area Professions Code The Contractor's License Law A
nes lot apply
to
area
owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a calibrations)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractors License Law.
I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dann WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKS RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 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 lScc.3800,Lah,C.).
Policy No. Connpany
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T@4
Z Z 0 Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
Applicant
F PERMIT ISSUANCE 10.00 FLooD zoNE A.L.U.L.
Cr - CF.R'I'IFICATV OF EXEMPTION FROM WORKERS'
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y[:] N❑
CIL O (This section need not be completed if the permit is for one TOTAL
::) Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
F mit Is issued,I shall not employ any person in any manner so as to
OO become subject to the Workers'Compensation Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH. 5.00
>_ N NOTICE TO APPLICANT': If after making this Certificate of Ex..
♦- ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
pro
visions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000GF.M) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10SMC.EM.) 6.00 SEISMIC FEE
1 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,Cie.C.).
Lend Cfa Nanrn HEATINGUNIT(OVER 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 is correct. 1 agree to comply with all city and county BOILER-COMM H.P.or 100,0008.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
above-mentioned property for inspection purposes.
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which :A CONST.TAX
may in any way accrue against said City in consequ nce of the PERMIT ISSUANCE 10.00
gr of this pcnmt. MECH.CONT. LIC.NO. MEC
MG g TOTAL TOTAL 3 -7OL/
H. p �1
\ � 2
Signature of Apphcant/Contractor J Il)' e
OFFICE COPY