8411 (2) POST THIS CARD NEAR FRONT.OF BUILDING
..PERMIT NUMBER
CITAr CUPERTINO 49 ' 8431
INSPECTION.DIVISION
V JOB.INSPECTION RECORD ^
PERMIT EXPIRATION "
JOB'ADDR ESS ✓ - WwIINIT# •' -LOT# PERMIT EXPIRES IF WORK '
OWNER - CONTRACTOR IS NOT STARTED WITHIN
INS CTION E "I INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU,
-ANCE OR 180 DAYS FROM
FOUNDATION cT p w .LASTCALLED INSPECTION.-
- UFER - / % �f ..
PREGUNITE
PERMIT VALIDATION .I_
� � � d 1G L
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED —
UNDERGROUND /SLAB
PLUMBING ' �6
ELECTRICAL Is5 ANCE DATE
MECHANICAL - - - - i EL CT PLG: MECH.
- •, El
DO NOT POUR FLOOR UNTIL ABOVE'HAS BEEN SIGNED BULLOtNG PERMIT
r INFORMATION
WOOD FLOOR - VALUATION $/FT,
PLUMBING -
` MECHANICAL.
ELECTRICAL- - ER ITTO .
FRAMING - ��'
STORIES ' /, .'TYPE CONSTR.'"
INSULATION
'OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
' ` ROOF SO.FT.FLOOR PREA TOTAL ACREAGE,
DIAPHRAGM '
BUILDING USE
- RES' IND. CON ,PB Omx,
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED Q El El 0 0 '
ROUGHASSESSORS PARCEL NO
k '
PLUMBING
TRACT NO. PARCEL NO,
GAS TEST
MECHANICAL -
ACC.DATE ACC.FILE NO.
ELECTRICAL g'.-�yP• �. FINALS DATE INSP..
FRAMING _y8' SAN u ZONING ENG.SITE No.
INSULATION - PLUMBING
.. GAS ...
FIRESPRINK ENERGY T.74
MECHANICAL - -Y � N� Y"Q' N� '
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING,'
LATH—INTERIOR ELECTRICAL PLaoD zoNE A.L.u.c.
Y� N� '.Y � .N
, LATH—EXTERIOR. - _ FIRE DEPT. ,
SHEETROCK " GRADE FEESUMMARY
SHEAR INTERIOR , BUILDING -
SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING
FIREWALLS . ELECTRIC - 'PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY - 'SEISMIC FEE
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. "MICROFILMS
ARRANGE FOR INSPECTION,BY PHONING 252-4505, ELECTRIC
F ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
z PLEASE GIVE'JOB ADDRESS WHEN PHONING.
- 1 .
SEE PERMIT. FOR EXPIRATION DATE - ' MECHANICAL
CONST.TAX
IMPORTANT!
PLEASE READ REVERSE SIDE BEFORE TOTAL .
CALLING FOR FIN'AL.INSPECTION. y
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT IDENTI FICAT APPLICATION & PER 1`/y/
BUILDING •
�c L [YC a�o5 z /) BUILDING-ELECTRICAL-PLUMBING-MECHANICA4 8 411
OwNER'Sr _®G uuYz PLAN CHECK VALIDATION
NAME MA n / ELECTRIC PERMIT FEE
�/ CAU 2 PHONE '
CONTRACTORS
rv4mE OUTLETS-SWITCHES•RECEP 10.00/1.00ae r�
LIC.No. LIGHTING FIXTURES 10.0011.00
CONTRACTORS APPLIANCES
PHONE
4.00
\i ADDRESS
!� PHONE PANELS 10.00 DATE OF APPLICATION
gcHlrecT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER -
uc.NO. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT . 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 PAID
APPu
RA
ADDRESS cANrs MOTORS EE FEE SCH. ��/'
,/Wtl JCI,
' SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE MAY
30.00 city Y U�NCE'bliR•
�
< u affirm U I hereby affi (hat I am licensed under provisions of Chapter 9
w Q w (commencing with Section 7000)of Division 3 of the Business and ELECT.I PLG. MECH.
r o UsProfessions Code,and my license is in full force and effect. ❑ ❑ ❑
z o License Class Lic.Number
9 u H J Dale - Contractor
a ><s BUILDING PERMIT
a tc w a OWNER-BUILDER DECLARATION INFORMATION
MISC- REFER TO ORD
w ;LL w I hereby affirm[fiat 1 am exempt from the Contractor's License VALUATION $/FT.
F.. oj Law for the following mason. 7031.5,Business Professions PERMIT ISSUANCE 1680 ^
Code:Any city or county which requires a permit to construct,alter, /
C 4 00 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
C,LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
U,m m he is licensed pursuant to the provisions of the Contractor's License
r Z r Law(Chapter 9(commencingwith Section 7000)of Division 3 oflhe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
s=-$ the basis for the alleged exemption.Any violation of Section 7031.5 STONAES TYPE CONSTR.
i by any applicant for a permit subjects the applicant toacivil 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
Code:The Contractor's License Law does not apply to an owner of
•'✓'^; r., property,who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
iiiiiiiizb himulf or through his own employees,provided that such improve-
' / ments are not intended or offered for sale.I L however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of.completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING uSE
builder will have(he burden of proving that he did not build or im-
prove for purpose of toS IND CON PIS Other
le.). INDUSTRIAL WASTE INTER
❑' L as owner of the property, exclusively 0ructing with . 30.00 ❑ ❑ 0 0
licensed contractors to Construct thehe project(Sec..7 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to owner of property who builds improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
ntr -
caac(s for such projects with a contrtr actor icensed pursuant to
the Co r 's Li se SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ a e p A P. or this WATER HEATER W/VENT 6.00
O1on
roDate WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent lose'If-insure. ZONING ENG.SITE NO.
or a Certificate of Workers'Compensation Insurance,or.certified
-� copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified ropy is hereby furnished. FIRE SPRINK ENERGY T24
Z ❑ Certified copy is filed with the city inspection division. MISC.• REFER TO ORD.
Applicant Y❑ N� Y E] NE]
CCCFiRTI FICATE OF EXEMPTION FROM WORKERS'
y PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
� -
L COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d O (This section need not be completed if the permit is for one TOTAL Y❑ N� v NC]
Z hundred dollars(S 100)or less,)
U O 1 certify that in the performance of the work for which this per. QTY. MECHANICAL 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.
0 i Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you mus( forthwith comply with FEE
1..1 Such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=11F.M.16.00 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 which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATING U N IT IOV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address -
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
_• information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMPM H.P.Or 100,000 B.T.U.) 6.00 hereby autharize 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 CONST.TAX
may in any way accrue against said In consequence of the PERMIT ISSUANCE 10.00
gr"!of thisp}e�LL MECH.CONT. LIC.NO. - MECH.
L�p TOTAL TOTAL 9d
Si at reo Appliront/Contractor e '
OFFICE COPY