11528 (2)` POST THIS CARD NEAR FRONT OF BUILDING
PERMIT NUMBER
CITY OF CUPERTINO
INSPECTION DIVISION ;..•
JOB INSPECTION RECORD
`/ ,� \1` PERMIT EXPIRATION
JOB ADDRESS I I I�"� lel 1VAQ �/151F0, �./�' UNIT# LOT# _
/1 /j PERMIT EXPIRES IF WORK
OWNER ( k � CONTRACTOR I�'� �O [(�I 1 {`l' IS NOT STARTED WITHIN
I SP TION DATE INSPECTOR INSPECTION RECORD 18oDAYS OFPERMIT ISSU-
FOUNDATION ANCE OR 180 DAYS FROM
LASTCALLED INSPECTION.
UFER
PREGUNITE - - PER TION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED AUG — 3 15Pu
UNDERGROUND /SLAB
PLUMBING - City Of CUp&'Ilno
ELECTRICAL - - ISSUANCE DATE
MECHANICAL , EI G, E CT. �P G. ME ,
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED L£J BUILDING ERMI
WOOD FLOOR INFORMATION
. VALUATION, $/FT.
PLUMBING
V
MECHANICAL '
ELECTRICAL ;y//-! PERMT
• FRAMING - i (�h • e o
INSULATION - STORIES TYPE CONSTR.
OCG GROUP RES.UNITS'
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
` ROOF $O.FT,FLOOR AREi TOTAL ACREAGE
DIAPHRAGM
BUILDING USE
_
RESI IND CON PB Orner
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ El El El
ASSESSORS PARCEL NO.
' ROUGH
PLUMBING; - 7 -
TRACT No. PARCEL No.
GAS TEST
MECHANICAL
ELECTRICAL FINALS DATE INSP. ^cc.DATE ACC.FILE NO.
FRAMING "'y,/✓I. '�). SAN # ZONING ENG,SITE NO.
INSULATION C PLUMBING /
GAS
FIRE SPRINK ENERGY TZO
ME HAN AL'
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED H ATING •Y [3 NE] 'Y t] N�
LATH—INTERIOR E ECTRICAL Z FLooD zarvE aL.u.c.
LATH—EXTERIOR RE DEPT. v [:]' NO Y 0 N❑
SHEETROCK qRADE FEE SUMMARY
SHEAR INTERIOR ILDI / y frrf
SHEAR EXTERIOR TEMPORARY PPROVALS .BUILDING
FIREWALLS ELECTRIC PLAN CHECK
GAS '
FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE �J /
OCCUPANCYOF BUILDING ISNOTPERMITTEDUNTILBUILDING FINALISSIGNEDBY BUILDING INSPECTOR: MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252.4505, ELECTRIC
o� ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
PLEASE GIVE JOB ADDRESS WHEN PHONING.
Z
- 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
aGILDINq APPLICATION & PERMIT
ADDRESS 11528
' BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME �•�- OTV. ELECTRIC PERMIT FEE
RT PHONE
CONTRACTOR'S
NAME1 UTLETS-SWITCHES-RECEP 10.00/1.00
L c.ND. �7 t LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
AOORESS
BONE PANELS 10.00 DATE OF APPLICATION
onnCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00 Palm
ADDRESS Ess ENG' SPECIALCIRCUIT 5,00 LIDATION
ZIP EMP.METER OR POLE INS. 20.00 AUG "UG „ l�btr
ADDRESS MOTORS SEE FEE SCH. i1 l7
ADDRESS C
Vu SERVICE CHANGE 20.00 .City of Cupertino'
'
-00 LICENSED CONTRACTORS DECLARATION -
a u5 -1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H z- (Commencing with Section 7000)of Division 3 of the Business and
z Professions Code n my license is in lull forf
Z i D License ass Can Number
w H� Uete - Contractor
¢ - s
BUILDING PERII
m Ic¢ OWNER-BUILDER DECLARATION
o i D INFORMATION
w ; 1- I hereby affirm that 1 am exempt from the Contractor's License
y MISC.- REFER TO ORD VALUATION $/FT.
uO¢ Law forthe following reason.(Sec.
Business tocodProfessions PERMIT ISSUANCE 10.00
w 2 Code:Any city or county which structure permit o its issuance,
alter,
ac a:Q p Improve,demolish,Or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
u a O u requires the applicant for such permit to file a signed statement that 9 73 TOTAL PERMJJ
X$ he is licensed pursuant to the provisions of the Contractor's License
_ ii Law(Chapter 9(commencing with Section 7000)of Division 3 fthe may(
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE /
a r $ the basis for the alleged exemption.Any violation of Section 7031.5 TORIES PE CONSTR.
a3 - by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ 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
• properly who builds or improves(hereon,and who does such work FIXTURES.PER TRAP 5.DD SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the budding GAS-EA.SVSTEM-I fi.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 the burden of proving that he did not build or im- ES IND CON PB Omar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the properly,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 property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts for such projects with a contractoos)licensed pursuant to SEWER-SANITAR V-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
O I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
mason
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, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy themof(Sec.3800,Lab.C.L
Policy No. Company
O ❑ JCrfltied copy is hereby furnished. FIRE SPRINK ENERGY T-24
ZCert o i file with the fly lion Division,
O Applicant MISC.- REFER TO ORD. y❑ N❑ Y ❑ No
Fy PERMIT ISSUANCE 10.00 FLOOD ZONE A.E.U.C.
O:
CERTIFICATE OF EXEMPTION PROA WORKERS'
UI COMPENSATION INSURANCE P CO TR. LI .NO. PLG,
d a (This svelki.,need not be completed if the permit is for one TOTA Y❑ N❑ Y❑ N❑
Z hundred dollar.(S 100)or less.)
U O 1 certify that in the performance of the work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mil is issued,I shall not employ any person in any manner so as to
U become suhject to the Workers Compensation Laws of Califomia.
ELI Datc Applicant - ALTER OR ADD TO MECH. 5.00 FLDING
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 provisions of the Labor Code, you must forthwith comply with suh provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10AWC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 I hereby affirm that there is a construction lending agency for ' EXHAUST HOOD (WITH DUCT) 5.0the performance of the work for which this permit is issued(Sec. HEATING UNIT (TO 100,000 B.T.U.) B.003097.Civ.CJ.Lender's Name HEATING UNIT(OVER 100,000B.T.U.)9.50
Lender's Address
1 certify that I have read this application and state that IhC 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-COMPO H.P.or 100,000 B.T.U.) 6.00
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 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.
''jam s,' TOTAL / TOTAL
Signature of Applican/Con actor Dam T-' r
OFFICE COPY
r