14176 (2) POST THIS CARD NEAR FRONT OF BUILDING
' PFRM1IIL NUMOER
CITY OF 'CUPERTINO 14176-
INSPECTION DIVISION
I
JOB INSPECTION RECORD
PERMIT EXPIRATION'
JOB ADDRESS 669' LONNA LANE UIN1T4k " LOT#
I • PERMIT EXPIRES IF WORK
OWNER CHARLES MATHIS CONTRACTOR ALL WEATHER- HEATING IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION -- ANCE OR 180 DAYS FROM
LASTCALLED INSPECTION.
UFER
PREGUNITE PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED o
UNDERGROUND /SLAB ~
PLUMBING �'•. i
ELECTRICAL ISSUANCE DATE
MECHANICAL - SLOG. ELECT. PLG. -MECH. .,
-❑1 ❑ . ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR VALUATION
PLUMBING - -
MECHANICAL '
ELECTRICAL PERMIT TO
FRAMING "
NSU LATION - STORIES - TYPE CONSTR
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF SO.F'.FLOOR AREA TOTAL ACREAGE
DIAPHRAGM
BUILDING USE
r h REB. JND CON PB Olner '
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED YN�0 ❑ ❑ 0
ASSESSORS'PA RCEL NO.
ROUGH yI-: •
PLUMBING -
TRACT NO. PARCEL NO.
' GAS TEST
MECHANICAL
ELECTRICAL FINALS DATE INSP. A"'DATE ACC_FILENO.
FRAMING 1 SAN *
ZONING ENG.SITE NO
INSULATION - 'PLUMBING , '
GAS
MECHANICAL FIRE SPRINK ENERGY T 2
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING "� "o
LATH-INTERIOR ELECTRICAL FLOOD ZONE A.L.U.C.
LATH-EXTERIOR FIRE DEPT. Y❑ "❑ Y ❑ 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 FEEc
OCCUPANCYOF BUILDING'ISNOTPERMITTED UNTILBUILDING FINAL ISSIGNED BY BUILDING'INSPECTOR. MICROFILM.
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
F ONE WORKING-DAY BEFORE REQUIRED INSPECTION. PLUMBING
z PLEASE GIVE JOB ADDRESS WHEN PHONING: MECHANICAL t .
- SEE PERMIT FOR EXPIRATION DATE -
CONST.TAX
IMPORTANT!
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICECOPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
-BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING 14176 _
ADD ESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
owrvER PLAN CHECK VALIDATION
N ` OTY- ELECTRIC PERMIT FEEfty-
J
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
TfiC� L�eaNne✓ Ne�ti ny _ C2D
!� •' uc.No. 5 LIGHTING FIXTURES .10.00/1.00
rXX,TTRAC1TO1RYa /,, �Ir PPLIANCES-RESIDENTIAL - 4.00
�_• Sµ"('�4 �
Ave
PHONE `1jI� II PANELS 10.00 DATE OF APPLICATION
ARCHITECT
PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER )DD
• . uc.No. SIGNS TRANS.
ARCH.OR ENG. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00 '
APPLICANTS MOTORS - SEE FEE SCH.
ADOflE55 U�•e 'e"
SERVICE CHANGE 2000.
t(
w o a LICENSED CONTRACTORS DECLARATION 7
<u v. I hereby affirm that I am licensed under Orovisions of Chapter 9 ISSUANCE DATE
y< i7 (commencing with Section 7000)of Division 3 0l the Business anJ - BLDG. ELECT. PLG. MECH.
F w Z professions Cod d y license is in full for�gn}I -f act ❑ ❑ ❑
z
0 . - LicenV s Lir.Number_](p
AP
Q z H 5.Q Date Contractor
a xBUILDING PERMIT
a w u OWNER-BUILDER DECLARATION INFORMATION
w g LL r I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
VALUATION S/FT.
Fu0 J Law forthe followingoason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requiresa permit to construct,alter,
s ¢Q FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIQ NO. ELEC. -
0 u requires the applicant for such permit to fila a signed statement that TOTAL PERMIT T
w$w he is licensed pursuant to the provisions of the Contractor's License - e
ve z) Law(Chapter 9(commencingwith Section 7000)of Division 3 ofihe k T,^
< Business and Professions Code)or that.he is exempt therefrom and DTV. PLUMBING PERMIT FEE {
It the basis far the alleged exemption.Any violation of Section 7031.5 Imo- - STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN&VENT-WATER IEA.) 5.00
of not more Ihan five bund red dollars IS500j)
❑ 'I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 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 such work FIXTURES-PER TRAP 5.00 SG.FT.FLOOR AREA TOTALACREAGE-
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00 .
ments are not intended or offered for sale.If,however,the building
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- RES INDCON PB fisher
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ F-1 110 I,as owner of the property,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 contractors)licensed pursuant to SEWER-SANPARCEL NO,
ITARY-STORM EA.200ft/10.00 TRACT NO..
the Contractor's License Law.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00 '
reason
Owner Date WATER SYSTEM 5.00ACC.OATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.CJAk g�B.tOY f�n{15(vJl
Policy No. Company�-�-1
O ,I ❑ Certified copy is hereby furnisFed. FIRE SPRINK ENERGY T 24
'Z Z P b( Certifi . isr filed witlt.eti c inspecn_ _'qn division. MISC.- REFER TO ORD.
A Plicant n .(Q f jsgW4^(t v N v N
F y / PERMIT ISSUANCE 10,00 FLOOD ZONE A.L.U.C.
CC - CERTIFICATE OF EXEMPTION FROM WORKERS'
LLI > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. TOTAL Y❑ NY ❑ NE]
CL Cl (This section need not be completed if the permit is for one
::) Z hundred dollars0100)or less.) - \
L) O 1 certify that in the performance of the work for which this per- n4sd MECHANICAL PERMIT FELL E FEE SUMMARY
mit is issued,I shall not employ any person in any manner So as to "/'A`
O W become subject to the Workem'Compensetic Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH.' 5.00 -
} r6i) NOTICE TO APPLICANT: If,after making this Certificate of Ex
2 emption,you should become Subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply With FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10A00C.F.M.)„4.00 II��
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT 10=C-F.M.) 6.00 SEISMIC FEE.
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 MICROFILM
the performance of the work for which this permit is issued(Sec.
3097,Civ.C.). 1 HEATING UNIT(TO 100,000 B.T.U.) B.00
Lender's Name - HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lenders Address
I certify that l havereadthisapplication and State that the above VENTILATION FAN (SINGLE) 4.00 PLUMBING
information is correct.1 agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
ordinances and State laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 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 PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
gran g of 1 is permit. I / �f MECH.CONT. _ LIC.NO. MECH.
SIF iWMW1 TOTAL Q TOTAL
Signature 0f AppocantjContraclor Da V/
OFFICE COPY