10836 (2) POST THIS CARD NEAR FRONT OF BUILDING
PrRMIT NUMBER
CITY OF CUPERTINO
INSPECTION DIVISION 10836
JOB INSPECTION RECORD
�/ /� '7 PERMIT EXPIRATION
JOB ADDRESS JLlL_L'1 �/ UNIT# LOT#
^ , ,l� PERMIT EXPIRES IF WORK
OWNER. CONTRACTOR Gc�/11A�/EI IS NOT STARTED WITHIN
INSPECTION DATE I INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
ANCE OR 180 DAYS FROM
LASTCALLED INSPECTION.
UFER
PERMIT VALIDATION
PREGUNITE
t
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
??C I
UNDERGROUND /SLAB
PLUMBING Y
ELECTRICAL .IDA rE
BLDG ELECT, PLG. MECH.
MECHANICAL El 0
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR VALUATION $/FT.
PLUMBING
MECHANICAL
ELECTRICAL / PERro
I
FRAMING
STO IES iv CO TR.
INSULATION
OCC.GROUP RES,UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
$O.FT.('LOOK AREA TOTAL ACREAGE
ROOF
DIAPHRAGM
BUILDING USE
RES IND CON PB Olney
I El El 0
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED
ASSESSORS PARCEL NO.
ROUGH
PLUMBING 1-(/- ,
TRACT NO PARCEL NO,
GAS TEST
MECHANICAL
ACG DATE ACC.FILE NO.
ELECTRICAL FINALS DATE INSP.
FRAMING VtiA S'4NA ZONING ENG,SITE NO.
INSULATION PLUMBING
GAS
FIRE SPRINK ENERGY T24
MECHAN Y ❑ NE] Y ❑ NO
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATIN
FLOOD ZONE 0.L.0 C.
LATH-INTERIO 13-Sy ELECTRI AL
LATH-EXTERIOR 0 FIRE DEPT. vo NE] Yo No
SHEETROCK 7a--1/- GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING ^'j`YG BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS
FIREWALLS ELECTRICPLAN CHECK
FEE
GAS
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCY OF BUILDING IS NOTPERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
)
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
uJ ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
O PLEASE GIVE JOB ADDRESS WHEN PHONING.
Z MECHANICAL
- SEE PERMIT FOR EXPIRATION DATE -
CONST.TAX
I IMPORTANT!
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
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BGILOING APPLICATION & PERMIT O
a00RE5E
BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
�1 836
Rs wec PLAN CHECK VALIDATION
NAME
HONE QTY. ELECTRIC PERMIT FEE
�1 r/ANTRacraRs UTLETS-SWITCHES-RECEP 10.00!1.00
N
L NAME �[
LIC.N LIGHTING FIXTURES 10.00/1.00
rorvrRAcroRs APPLIANCES-RESIDENTIAL 4.00
aooREss QQ
/T0 PHONE J PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No SIGNS TRANS. 3.00
ARCH.OR ENG. 5,00 PERMIT VALIDATION
AODRESS SPECIAL CIRCUIT
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS -
SERVICE CHANGE 20.00 '�-/
wo o LICENSED CONTRACTORS DECLARATION / �/
< U u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUA GE DATE
v, G w (connnencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w z professions Code,j +d my license is in full forc,H, ❑ ❑ ❑
z o m
;-Y License Cl Lia Number
Q m r Dmc-Conlranor
Q ar a OWNER-BUILDER DECLARAT N ILDING PERMIT
U REFER TO ORD INF fR TION
w3 LL N 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- . V UATI $/FT.
u, u
04 Law for the following reason.(Sec 7031.5,Businessand Professions -PERMIT ISSUANCE 10.00 L•
Code:Any city or county which requires a permit to construct,alter,
Q 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.IS 1n�
D S, requires the applicant for such permit to file a signed statement that - TOTAL ^' RMIT TO
n w m he is licensed pursuant to the provisions of the Contractor's License y
Law(Chapter 9(Commencing with Section 7000)of Division 3ofthe
4 Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
r o the basis for the alleged exemption Any violation of Section 7031.5 STORIES TVP ONSTR,
dam by any applicant for a permit subjects the applicant loacivil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(55000.):
❑ 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,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 S.00 50.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-11NC.4OUTLETS 6.00
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 lie did not build or im- RES IND CON PB Other
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,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 LicensC Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EAJ 1.00
contracts nuouor su License
ts Lwithucontmaots)licensed pursuantm SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ lam exempt under Sec.-,BAP.C.for this WATER HEATER WlVENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
WORKS RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,ora certified
/- copy thereof(Sec.3800,Lab Cf�
Policy No. Compapy
Q ❑ Certified copy DIM,
yI'umid. FIRE SPRINK ENERGY T2
Z Z J� Certified 'ny i ICJ Nt(-IhC C inspection division. MISC.- REFER TO ORD. V ❑ N� Y ❑ N❑
Aplllican[
CC - PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
� - CERTIFICATEOF PESAbIOTIFROM WORKERS'
UJ > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N F] Y ❑ N❑
CIL 0 this section need not he completed if' the permit is for one TOTAL
::) Z hundred dollars IS 100)or less)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued,I shall not employ any person in any manner so as to 9�.,
OW become subject to the Workers'Compensation Laws of California. BUILDING eCV
n Datc ApPlicatt ALTER OR ADD TO MECH. 5.00
} N NOTICE: TO AI'I'LICANTi If,after making this Certificate of Ex-
f.. ? emption.you should become subject to the Workers'Coin pensat ion APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.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. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.).
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I 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 BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and stale 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
abovo-mentioned property for inspection purposes.
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against ha, 'e',judgments, costs and expenses which CONST.TAX
PERMIT ISSUANCE 10.00
may iri any way Cru against id City in consequence of the
grand o i of MECH.CONT. LIC.NO. MECH.
\/ �f� � TOTAL TOTAL 13`0
X
Sig l atafe of A cant/Conductor Dale
%%\\ OFFICE C PY