12940 (2) POST THIS CARD-NEAR FRONT OF BUILDING
CITY OF CUPERTINO FFRN,IT NUMBER
a ., 12940
• ,• = INSPECTION DIVISION , , _ '- ,
JOB INSPECTION RECORD
.,
PERMIT EXPIRATION
JOB ADDRESSal C-d v,,y S.& UNIT# LOT# ' -
'' +A PERMIT EXPIRES IF WORK -
„ OWNER I!' /l./ CONTRACTOR �S"' yamCS
, - C IS NOT STARTED!WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-,
' - -ANCE•OR 180 DAYS FROM
FOUNDATION;_, - LASTCALLED INSPECTION.
UFER
PREGUNITE PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB i
PLUMBING _ . 'f
r
ELECTRICAL I .ISSUANCE.DATE
MECHAWCAL ULOG. ELECT. PLG. MECH,,
El
00 NOT POUR^FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING_PERMIT
'INFORMATION
WOOD FLOOR VALUATION
PLUMBING
MECHANICAL' - , ,'• 1O
Nb
ELECTRICAL RMITTO
- : �j"a$ 4
FRAMING - 7
STORIE ,.', TYPE'CONSTR.
INSULATION .. _ ' SC tt1�O.
OCC.GROUP RES.UNITS -
'PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED T
' . . , SO.FT-FLOOR AREA TOTAL ACREAGE'
ROOF
DIAPHRAGM <
BUILDING USE
RES IND CON PU O,hw
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑•' '❑ "❑ ❑` ❑
ASSESSORS PARCEL NO.
ROUGH-
PLUMBING —" "
TRACT NO. PARCEL NO.
' • GAS TEST , -
MECHANICAL '
FINALS, . ACC.DATE .ACG FLLENO.
- ,
ELECTRICAL .8'' DATE INSP. !
FRAMING _ - SAN # -
ZONING , ENG.SITE NO.
INSULATION. PLUMBING.. _
GAS
MECHANICAL' 'L-
FIRE SPRINK� ENERGY T 24
-•Zfr fc�'
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED I HEATING Y❑ 'N❑ Y ❑ "❑
LATH—INTERIOR b
ELECTRICALFLOOD ZONE, A.L.U,C,
LATH-EXTERIOR FIRE DEPT. Y❑ N❑ < Y❑ NF
SHEETROCK - GRADE - FEE SUMMARY
SHEAR.INTERIOR • BUILDING
' SHEAR EXTERIOR
TEMPORARY APPROVALS BUILoINc' -
FIREWALLS ' ' ELECTRICS' 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. MICROFILM
4
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC Ota
"' ONE.WORKING DAY BEFORE REQUIRED INSPECTION.
. - F PLUMBING
_ Z�'' PLEASE GIVE-JOB ADDRESS WHEN PHONING:
SEE PERNIMFOR EXPIRATION DATE — MECHANICAL
IMPORTANT! . ' covsT..TAx
PLEASE READ REVERSE SIDE BEFORE TOTAL,
i CALLING FOR FINAL INSPECTION.
. OFFICE COPY
APPLIC4NT.TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY .
BUILDING PROJECT I DENTIFICATION - PERMIT NUMBER
' aUILmNG APPLICATION & PERMIT 12940 n A O
DDRuIS^ SS /L BUILDING — ELECTRICAL—PLUMBING-MECHANICAL G `J' [{.
OWNERS J '/l-• PLAN CHECK VALIDATION
NAME 'J� OTY. ELECTRIC PERMIT FEE
PHONE
NAME c oRs /�///�� UTLETS-SWITCHES-RECEP 10.00/1.00
NAME `7
LIC.No, LIGHTING FIXTURES 10.00/1.00
CONTRACTORS37/Y,7—d/ APPLIANCES-R ESI DENTIAL 4.00
- ADDRESS
/ oN PANELS 10.00 DATE OF APPLICATION
ARCHI ECT PANELS (OVER-2OO AMP) 20.00 PLAN CHECKFEE P.C.NO.
t ENGINEER / LIC.No. - SIGNS TRANS. 3.00
1 ARCH,OR ENG. .. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS --• - /
- t 'ZIP TEMP.METER OR POLE INS. ' 20,00
APPLICANT'S - MOTORS y SEE FEE SCH.
ADDRESS SERVICE CHANGE 20.00 7/S
F o o LICENSED CONTRACTORS DECLARATION
¢E,, u I hereby affirm that I am licensed under provisions of Chapter 9 - ISSUANCE DATE
v~i Q y (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H. D i Professions Co and my license is in full for and e f c ❑ - ❑ ❑
z o 0-- License ss ¢.Number //,(yCyt,
Q m L w Date�/��J/Y, [/Q�/�Contractor ` ��yJ� _
te 1¢ J, / �e" `' ION BUILDING PERMIT
¢ ¢ 0 OWNF-R-BUILDER DECLARATION INFORMATION
A O y U
wa. y 1 hereby:doom that I am exempt from the Contractor's License MISC:— REFER TVkD
u o j Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 1Q 00 0 VALUATION $/FT.
't W Code:Any city or county which requires❑permit to construct,alter,
SE
ea< Fo improve,demolish,or repair any structure,prior to its issuanec,•also ELE 0 R. IC.NO. ELE '
D¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w m u he is licensed pursuant to the provisions of the Contractor's License ALLY y�
So 9(commencing with Section 7000)of Division 3 ofthe G
a - Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ r $ the basis for the alleged exemption.Any violation Of Section 7031.5 STORIES TYPE CONSTR.
a3 � by any applicant for a permit subjects the applicant to a civil peoulty ALTER-DRAIN&VENT-WATER (EA.) 5.00 -
of not more than five hundred dollars(S500)J:
❑ [,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP I RES.UNITS
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
. properly who builds or improves thereon,and who does such work FIXTURES,PER TRAP 5.00 SO.,FT,FLOOR AREA TOTAL ACREAGE
himself or through e
his own employees,provided that such improv '
.cuts are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4 OUTLETS, 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 IEA) 200
builder will have the burden of proving that h . .
e did not build or im- . BUILDING USE
prove for purpose of sale.). I NDUSTRIALWASTE INTER. 30.00 RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with ❑ .❑ ❑ ❑ -❑
licensed.contraclors 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 property 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-SANITAR V-STORM EA.200ft/10.00
the Contractors Lwense Law. TRACT NO. PARCEL NO,
❑ lam exempt under Sac.—,B.&P.C.for this WATER HEATER W/VENT - 6.00
reason-
Owner Date WATER SYSTEM 5.00
ACC.-DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.). -
Policy No. Company "
Q ❑ Ce 'fieri copy is herby furnished FIRE SPRINK ENERGY T-24
Z Z erl ified �IeJ w' �inspemion,division' MISC.- - REFER TO ORD.
0 Appheam� �1 r ❑ N❑ Y ❑ N❑
y ; PERMIT ISSUANCE. - 10,00
�
CERTIFICATE OF EXEMPTION FROM WORKERS' FLOOD ZONE A.L.U.c.
lU > • COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d O (This section need not be completed if the.permit Is for one - TOTAL Y❑ IN Y ❑ IN
Z hundred dollars IS 100)or lwsJ '
U 0 1 certify that in the performance of the work for which this per OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I. mil is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
Date Applicant - ALTER OR ADD TO MECH. 5.00 .BUILDING
} m NOTICE TO APPLICANT: If,after making this Certificate of IN:
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 AIR HANDLING UNIT(TO 10 FEE'
U such provisions or this permit shall be deemed revoked. =421F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.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 He work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.)- 8.00 MICROFILM
3097,Civ.C.).. -
Leader'sName - HEATING UNIT(OVER 100,900B.T.U.)9.50 . ELECTRIC
Lender's Address
1 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 gpILER•QJMP 13 H.P.Dr 100,900 B.T.U.) fi.00 PLUMBING
ordinances and stale laws relating to building construction,'and
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP(Over 100,000 BTU)SEE FEE'SCH. MECHANICAL
-
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, cosy and expenses which CONST.TAX
may in any way neem gains[ s ' In'conseyuenro of the PERMIT ISSUANCE 10.00
Sinn ling of if sPi' BCH.CONT. LIQ NO. - MECH.
TOTAL TOTAL
Signurcof Applicant/Contructor e
OFFICE COPY