12794 (2) POST THIS CARD NEAR FRONT OF BUILDING
PERMIT NUMBER
• CITY OF CUPERTINO 12794
INSPECTION DIVISION
JOB IN PECTION RECORD
lei - • PERMIT EXPIRATION
1 JOBADDRE UNI _LOT#
PERMIT EXPIRES IF WORK
OWNER TRACTOR IS NOT STARTED WITHIN
INSPEICTION DATE INSPE OR INSPECTI0,WRECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION ANCE OR 180 DAYS FROM
UFER
LASTCALLED INSPECTION.
PREGUNITE PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB
PLUMBING 2-;.3-8T)
ELECTRICAL
ISSUANCE DATE
MECHANICAL BLDG ELECT PLG. MECH.
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUIL I PE M T
WOOD FLOOR . INFORMATION
PLUMBING
VALUATION $SFT.
1
MECHANICAL -�u� v
ELECTRICAL / PEERR�MITTO (
FRAMING (( / , AI]]�'�JL
INSULATION SrRIES TYPE CONSTR.
OCG GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF SO.FT,FLOOR AREA TOTALACREAGE
DIAPHRAGM '
BUILDING USE
R IND CON PB Other
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED 1,V ❑ ❑ ❑ ❑
ROUGH
/ ASSESSORS PARCEL NO.
//
PLUMBING
GAS TEST TRACT NO. PARCEL NO.
MECHANICAL
ELECTRICAL T 3.2 _ FINALS DATE INSP. ACC.DATE ACC FILE NO.
FRAMING }, ((v ,y- SAN #
INSULATION -129- � PLUMBING ZONING ENG.SITE NO.
GAS
MECHANICAL FIRE SPRINK ENERGY T 1
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y❑ N❑ Y ❑ No
LATH-INTERIOR ELECTRICAL FLOOD ZONE a,L.U.C.
LATH-EXTERIOR FIRE DEPT. Y❑ N❑ Y ❑ N❑
SHEETROCK _Y GRADE
SHEAR INTERIOR FEE SUMMARY
BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING
FIREWALLS ELECTRIC PLAN CHECK
GAS IFEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED occuaglvcv SEISMIC FEE
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR.
t MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
o� ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
Z PLEASE GIVE JOB ADDRESS WHEN PHONING.
— SEE PERMIT FOR EXPIRATION DATE — MECHANICAL
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
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS7 . UILDING-ELECTRICAL-PLUMBING-MECHANICAL� ��; I� [
OWNER'S, _ PLAN CHECK VALIDATION
NAMEff��//x64q,/xea�,�,, (( (� QTY. ELECTRIC PERMIT FEE
f�✓[.Jr'-C.I•S �a0 U/tom] PHONE
CONTRACTORS
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
TR�C T / �`
(/rte- / T Lm.NO,"06s6 'Z LIGHTING FIXTURES 10.00/1.0
CONTRACTOR SAPPLIANCES
-RESIDENTIAL 4.0
DDF E55
yp C- .5T. 636 Y PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLA FEE P.C.No.
OR
O
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG, SP46&FECIAL CIRCUIT 5.00 EaMIT VALIDATION
ZIP EMP. METER OR POLE INS. 20.00 J 1,987
ARMOTORS SEE FEE SCH.
ADDRESS
SERVICE CHA GE 20.00
C LICENSED CONTRACTORS DECLARATION
Q U. I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
h-z w (commencing with Section 7000)of Division 3 of the Business and aBLD ELE P G. MECH.
r w Professions Code nd my license is in full force and effect. ❑
z o w- License Cir
Li, Number / EX
9 z _ate Contractor
er m s BUI DING RMIT
IS IS a OWNER-BUILDER DECLARATION
i " MISC.- REF ER TO ORD INFORM TION
w ;LL h 1 hereby affirm that I am exempt from the Contractor's License
H u o a Law for the following reason.(Sec.7031.5,Businessand Professions pERMIT ISSUANCE 10.00 V LUATION SIFT.
Code:Any city or county which requires a permit to construct,alter,
2< improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O, requires the applicant for such permit to file a signed statement that TOT
e. w m u he is licensed pursuant to the provisions of the Contractors License PERMIT T
HiQ Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
s 4 D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
X 1- $ the basis for the alleged exemption.Any violation of Section 7031.5 5 DRIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars(S500).): ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ 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,AR EA,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 workFIXTURES-PER TRAP 5.00 70,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
Of improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RS IND CON PB other
Cl 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7IM4,BusinessLAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or iniproves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forsuch projectswith acontractons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft 10.00
the Contractors License Law. / TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
fea50n
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy Ihereof(Sec.3800,Lab.CJ. t
Policy Company F2AAIX 01&On$Oh4
C) llified copy is hereby furnished. FIRE BPRINK ENERGY T 24
Z 2 ❑ Certified copy is filed with th 'ly . p tion division.
F- 0 pplicant x,l t1-'ten/ K. aLil z MISC.- REFER TO ORD. Y Q NE] Y [] NE]
� N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00FLO DzoNE A.L.u.c.
d
L COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLC
.
(This Section need not be Completed if the permit is for one TOTAL Y N-0 Y N
2 hundred dollars(S 100)or IcssJ
U 0 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued, I shall not employ any person in any manner so as to
O L) become subject to the Workers'Compensation Laws of California. zr
CU Date Applicant ALTER OR ADD TO MECH. 5,00 BUILDING J
>_ W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
f.- ? eruption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with U FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=1C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.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 the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have"ad'his application and state that the above VENTILATION FAN (SINGLE) 4.00 -
information is correct. 1 agree to comply with ail city and county BOILER- H.P.or 100,000 B.T.U.) 6,00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the g01 LER-COMP (Over 100,000 BTU)SEE FEE SCH.
above-mentioned property -
for inspection purposes. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which' pERMIT ISSUANCE 10,00 CONST.TAX
may in any way accrue against said City in consequence of the
granting of this permit. �� MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
ignature Applicon Comracmr Date
OFFICE COPY