12340 (2) POST THIS D NEAR FRONT OF,,;pUILDING
CITTOF CUPERTINO RMITNDMREdR
INSPECTION DIVISION Z34�
JOB INSPECTION RECORD
,I PERMIT EXPIRATION
JOB ADDRESS Jo - UNIT# lOT# PERMIT EXPIRES IF WORK
OWNER A
CONTRACTOR IS NOT STARTED WITHIN
INSPECTION ATE I INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
@ ANCE OR 180 DAYS FROM
FOUNDATION �- 7-• O 0 'S LASTCALLED INSPECTION.'
UFER
PREGUNITE PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BE N SIGNED '
UNDERGROUND /SLAB
. PLUMBING K
ELECTRICAL ISSUANCE DATE
MECH.
MECHANICAL 9LDG. ELECT. 'PLG.
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION kr,
WOOD FLOOR VALUATION $/FT.
PLUMBING
MECHANICAL
ELECTRICAL PERMIT TO
�)
FRAMING - /?F,T&N- "" � •'
STORIES TYPE CONSTR.
INSULATION -
OCC.GROUP RES.UNITS
_ PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
SO.FT.FLOOR AREA TOTAL ACREAGE
'ROOF '
�) DIAPHRAGM
BUILDING USE
- ' - RES IND CON PB Other
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED 0 0 E-1 E 11
ASSESSORS PARCEL NO.,
ROUGH
PLUMBING
TRACT NO. PARCEL NO.
GAS TEST
i
MECHANICAL `
ELECTRICAL FINALS DATE INSP. All,DATE ACC.FILE NO.
FRAMING - SAN #,
ZONING ENG.SITE NO,
INSULATION PLUMBING '
GAS
MECHANICAL FIRE SPRINK ENERGY T 24
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING ❑ "❑ "�
LATH-INTERIOR - ELECTRICAL FLOOD ZONE A.L.U.C.
LATH-EXTERIOR FIRE DEPT. YE] NY'❑ N❑
SHEETROCK - GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING _
SHEAR EXTERIOR, TEMPORARY APPROVALS- BUILDING
FIREWALLS - ELECTRIC, PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED JOCCUPANCY SEISMIC FEE S
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
LU
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 INF ATION WITHIN RED LINES - USE LL POINT PEN ONLY
-Buff6iNGPROJECT 1 DENTI FIC NPERMIT NUMBER
9U*DRNG , A APPLICATION & PEWIT
12340
I- ADDRE /SS O / ^
'J` BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWN PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE
i
CONTRACTORS' PHDNE `..
' UTLETS-SWITCHES-RECEP 10.0011,00
NAME
LIC.NO, LIGHTING FIXTURES 10.00/1.00
ADDRESc7DRs APPLIANCES-RESIDENTIAL 4.00 '
CONTRAS
PHONE PANELS 10.00 DATE OF APPLICATION
RcwrecT PANELS (OVER 200 AMP) 2000 PLAN CHECK FEE P.C.NO.
O
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG.
SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'SW,
MOTORS SEE FEE SCH. A ,
ADDRESS ^•�/�-
SERVICE CHANGE 20.00
Woo
LICENSED CONTRACTORS DECLARATION 6 ��' /• tL
a v v 1 hereby affirm that I am licensed under provisions of Chapter 9ISSUANCE DATE
y a vawi (commencing with Section 7000)of Division 3 ol'the Business and PLG. MECH.
F y z Professions Code,and my license is in full force and effect ❑ ❑
z D ve License Class Lie.Number
LD z - Date Contractor
¢ Y s - BUILDING PERMIT
a w u
OWNER-BUILDER DECLARATION INFORMATION
e. oa MISC.- - REFER TO ORD
w ; I- I hereby affirm that I am exempt from the Contractor's License vALUATtON S/FT.
F S,o j Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE - 10.00
Code:AnycRyorcounly which requiresa permit to construct,alter,
rc ¢ ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
i O u requires the applicant For such permit to file a signed statement that TOTAL
Kw PERMIT TO
$ m he is licensed pursuant to the provisions of the Contractor's License q 7
Hi > Law(Chapter 9(commencing with Section 7000)o(Division 3 ofthe �I(�- gwy� tC44-(-,(✓i
4 er Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
Ie H the basis foFthe alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i by any applicant for a permit subjects the applicant loo civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(4500).):
❑ 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(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
Property who builds or improves thereon,and who does suds work FIXTURES,PER TRAP 5,00 ED.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-11NC.40UTLETS 6,00
mems are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
prove for purpose of sale.). . INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ 1,as owner of the propany,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.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 an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL N0.
❑ lam ex i ec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM - 5.00
ACC.GATE ALC.FILE NO,
WORK F.RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate o(consent to sal&insure, t ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z O ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
Applicant V N V N
Fos PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
� CERTIFICATE OF EXEMPTION FROM WORKERS'
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y❑ N❑
a- Z (This section need not be completed if the permit is for one TOTAL
hundred dollurs($100)ar less.)
C)'O 1 certify that in the performance of the work(or which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARV
LL H 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.
yDate Applicant ALTER OR ADD TO MECH. 5.00 BUILDING 3,Z J�
} to NOTICE TO APPLICANT: If,after making this Certificate of F:x-
L.. Z 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
C..1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000CF.NL) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10MC.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.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and slate laws relating to 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 BOI LER-COMP Wear 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly 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 City in consequence of the PERMIT ISSUANCE 10.00
gr of this pe t' MECH.CONT. LIC.NO. MECH. _
t t--6-k(, TOTAL TOTAL �J
t r u (A icanl/Cont or Date
OFFICE COPY