13011 (2) POST THIS C NEAR FRONT OF BUILDING • PPRM1,ITNUMBER
CITAF CUPERTINO
INSPECTION DIVISION 13011
JOB INSPECTION RECORD
/L I PERMIT EXPIRATION
JOB'ADDR/E?SS/�2 � �i//7��V /JDLIJ k UNIT# LOT
/# Q PERMIT EXPIRES IF WORK
OWNER IJ'rC (T - /� ��' CONTRACTOR /'z��U L Al 1-17 LJ IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION ANCE OR 100 DAYS FROM
LAST CALLED INSPECTION.
UFER
PERMIT VALIDATION -
PREGUNITE '
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB -
PLUMBING Z
ELECTRICAL ISSUANCE DATE
BLDG. ELECT, P G. MECH.
MECHANICAL'
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR VALUATION SIFT.
PLUMBING
MECHANICAL
ELECTRICAL Fri T
FRAMING ,P/
STORIES T PE CONSTR.
INSULATION
C W o .
UCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF +SQ FT.FIDOH AREA TOTAL ACREAGE
• DIAPHRAGM
BUILDING USE
RES IND CON PB OIM1M1
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED - 1:1 El 1:1 ❑ 1:1'I
ROU GH ASSESSORS PARCEL NO.
. .
PLUMBING
GAS TEST 4. I j,JO TRACT No. PARCEL No.
MECHANICAL - I
ELECTRICAL .ACC.DATE ACC.FILE.NO.
-,�/' FINALS T (NSP.
FRAMING SAN *
ZONING ENG.SITE NO.
INSULATION PLUMBING
GAS
MECHANICAL FIRESPRINK ENERGY T 24
'
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y ❑ N❑ Y ❑ NF)
LATH-INTERIOR ELECTRICAL FLOOD ZONE A.L.U.C.
LATH-EXTERIOR FIRE DEPT. Yo ND Y ❑ "0
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 OCCUPANCY SEISMIC FEE
OCCUPANCVOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINALISSIGNEDBY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING ✓
O 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 .
API*LICANT TO FILL IN INFORUkTION WITHIN RED LINES - USE BAI POINT PEN ONLY
• BUILDING PROJECT IDENTI FICATI PERMIT NUMBER
BUILDIN „ APPLICATION PERIVV
^�• ADDRE
D Ran 6mul fie BUILDING - ELECTRICAL-PLUMBING-MECHANICAL13011
OW+�LQR'S PLAN CHECK VALIDATION
• "AMT CITY. ELECTRIC PERMIT FEE
6 o roa NE
CONTRACTOR
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME A
(„Q uc.NO. LIGHTING FIXTURES 10.00/1.00
P,ONTRACTOR'sfae PPLIANCES-RESIDENTIAL 4.00
ADOR s��sJJ y
j(Y♦ Q Ipg& PHONE o7 PANELS 10.00 DATE OF APPLICATION
ARCHITECT*� O ^• IT' PANELS (OVER 200 AMP) 2Q,QQ PLAN CHECK FEE P.C.NO.
OR YT a
ENGINEER
LIC.No, SIGNS TRANS. 3,00
ADDRESS ENR. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. PAID
ADDRESS
SERVICE CHANGE 20.00 1
W O O 70 LICENSED CONTRACTORS DECLARATION MAY 2 0 70
a u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSU E OA
N.Q$ (commencing with Section 7000)of Division 3 of the Business and BLDG. MECH.
F 0 z Professions Code, nd y license is in full for e a of c ❑ ❑ ❑
z O y License Cla Lic.NmnM1er _ _
0 T rat Daec�Contractor
, E BUILDING PERMIT
OWNER-BUILDER DECLARATION
a al U INFORMATION
oa. MISC.- REFER TO ORD
X
; H I hereby affirm that I am exempt from the Contractor's License
.. o a Law for the following reason.(Sec.703 1.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
� - -1 Code:Any city orcounty which requires a permit to construm,alter.
ac aa¢2O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
E O LL requires the applicant for such permit to file a signed statement that TOTAL PE
A w $a he is licensed pursuant to the provisions of the Contractor's License /
HZT 710
La..(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and G Y. PLUMBING PERMIT FEE
F o the basis for the alleged exemption.Any violation Of Section7031.5 STORIES TYPE CONSTR.
Laam by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(55001.):
❑ 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 5.00 Q SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 A TLETS 6.00 00
or improvement is Sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 1 2.00 BUILDING USE
builder will have the burden of proving that he did not build or in,.
prove for purpose of sale.). INDUSTRIALW NTE 30.00 'RES IND CON PB oma,
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors 10 construct the project(Sec.7044,Business LAWN SPR IN KL - 1 INC 5 V.B, 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to as owner of property who builds or improves thereon,and who LAWN SPRINKLE U 1.00
contracts for such projects with a contractor(s)licensed Pursuant to SEWER-SANITARY-S ORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec,-,B.&P.C.I'or this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ecl&v ACC.DATE ACC.FILE NO.
WORKF.RS'COMPENSATION DECLARATION WATER TREATINd%QUW 5.00
1 hereby affirm that 1 have a certificate ofconsent to self-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a c reified ENG.SITE NO.
x copy thereof(Sec.
)
11� 1987
Policy N Company JS / r
Q ❑ Certified copy is hereby furnished,
Mrg� FIRESPRINK ENERGY T-24
z Ap Certified p is Jed wi to l eclion divisimt. MISC.- COMMA TO ORD. ❑ ❑ ❑ ❑
O PP scan[ � v N v N
� y CERTI FICATE OF EXEM PTION I7ROM WORKS RS' PERMIT ISSUANCE 10.00 pro'v FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE: PLG.CONTR. LIC.NO. PLG.
�
Z( This section need not be completed if the permit is for one TOTAL Y E] IN[] El
❑ N
hundred dollars IS 100)or Icss.)
U O I certify that in the performance of the work for which this per CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued, I shall not employ any person in any ntannerso as to
Ow become subject to the Workers Compensation Laws of California. BUILDING
y Date Applicant ALTER OR ADD TO MECH. 5.00
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
♦- Z emplion,you should become subject to the Workers'Compensation 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=CF.M.) 4.00
CONSTRUCT ION 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
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9,50 ELECTRIC
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 PLUMBING -7
ordinances and state laws relating to building construction, and BOILER-COMPOH.P.or 100,000B.T.U.) 6.00 /v
hereby authorize representatives of this city to enter upon the BOILER-COMP Over 100,000BTU1SEE FEESCH. 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 consaquence of the
granting of this permit. MECH.CONT. LIC.NO. MECH.
METAL TOTAL
YSignature of Applicant/Contractor Date
OFFICE COPY