11404 (2) POST THIS RD NEAR FRONT OF BUILDING
PERMIT NUMBER
. , CCITT OF` CUPERTINU.".' A
INSPECTION''DIVISION' To
JOB.INSPECTION'RECORD r,
Ad /1 PERMIT EXPIRATION -
JOBADDRESS' � K��QQQ(�/Jlr J/T rlµKt d UNIT LOT.#
j. r ',PERMIT EXPIRES IF WORK
OWNER L,1 Z -CONTRACTOR -IS NOT STARTED'WITHIN
INSPECTION DATE INSP CTOR INVECTION RECORD 180 DAYS OF PERMIT ISSU;
FOUNDATION Z ����� (/�� -'P ANCE OR 180 DAYS FROM
LIFER F / ' LAST CALLED INSPECTION. •,
PR EGUNITE '� •. spy PERMIT VA DATION•.
" ;,� •i
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
1
UNDERGROUND'?SLAB
'PLUMBING
ELECTRICAL - ISSUANCE UATE
_ MECHANICAL - yBIOG. ELECT. PLG.' MECH.
. ❑. ED El 3's
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED' - " BUILDING PERMIT
PLUMBING
WOO D.FLOOR - . INFORMATION
, .F vgwnnDN
MECHANICAL'- -
ELECTRICAL
PERMIT T
�„���,� _3, - �
FRAMING 'P. •376Qn&a '�.%/✓"I.
INSULATION _ • , STORIES TYPE CONSTR.
- - ..
OCC.GROUP RES,UNIT5
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
• ROOF SO.FT FLOOR AREA TOTALACREAGE
• DIAPHRAGM . -
`L§ 1. •r ZII EE `. IND 1LOCON USEPB One.
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED A� o 1:1 1:1 0
ROUGH ' ASSESSORS PARCEL NO.
PLUMBING -
GAS TEST P.E. Zlf,7 mr&/for-vA/m- '. I RACT NO, PARCEL N0.
MECHANICAL
ELECTRICAL pq.o- 6' _ FINALS DATE INSP. ACC.DATE ACC.FiLENO.-
FRAMING _ - SAN # -
INSULATION '�.. _�6' PLUMBING . .'I.7• Q?, 2°Nwc ENG.SITE ND.
k
- GAS ., p
MECHANICAL. I / 'FIRE SPRINK ENERGYT24
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED ; HEATING - �:, - ` E) "� •°i�' "d
LATH-INTERIOR , - ELECTRICAL- -- FiooD zoNE .A,L.u.c.
: LATH-EXTERIOR FIRE DEPT: OL
�°0 "�' �'� "[
SHEETROCK' I :. . . GRADE " FEE SUMMARY
SHEAR INTERIOR. ' - BUILDING )77
SHEAR EXTERIOR - " ' • ' TEMPORARY APPROVALS, BUILDING ,,� �' raj
FIREWALLS - 'r"• ELECTRIC PLAN CHECK
GAS _ FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY 'SEISMIC FEE
OCCUPANCY OF BUILDING IS NOT PERMITTEDUNTIL BUILDWG FINAL�IS SIGNED BY BUILDINGINSPECTOR. MICROFILM . -
,F �.
ARRANGE FOR INSPECTION BY`PHONING 252-4505„ 4� ,L ELECTRIC'
0o ONE WORKING.DAY BEFORE'REQUIRED INSPECTION `' r'
PLEASE GIVE JOB ADDRESS WHEN PHONING. , PLUMBING
Z MECHANICAL '
- SEE PERMIT FOR EXPIRATION-DATE
IMPORTANT!
CONST.TAX F r
PLEAS E'READ REVERSE SIDE BEFORE' ° TOETAL 1�C
CALLING FOR FINAL INSPECTION:
.. r . , .. OFFICE COPY',
•APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
• BUILDING PROJECT IDENTIFICI PERMITNUMBER
BUILDING APPLICATION & PET
ADDRESS
0. 805- I)Q �,F^G- Rd BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 111404
OWNER'S - PLAN CHECK VALIDATION
"//g�1q//�E .O ///,.-,. J/ 401{J"/, � QTY. ELECTRIC PERMIT FEE 1
lox' / L�l V GUCJZU� PHONE /%�"� ..
CONT
ACTORS W1y'K '
' .Ll 9-✓'/Z7 OUTLETS-SWITCHES--RECEP 10.00/1.00NAME
�S
S2o+?2 LIC.NO Jr LIGHTING FIXTURES 10.00/1.00 /0
-
CONTRACTORS - - PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE. PANELS 10.00 d DATE OF APPLICATION
RCHrtECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
O
ENGINEER' ,
LIC.No. SIGNS TRANS. 3,00
ARCH,OR END. - SPECIAL CIRCUIT- 5,00 PERMIT VALIDATION
ADDRESS . - ,.
�zlv ITEMP.METER OR POLE INS. 20.00
APPLICANT'S - - MOTORS S H. A
ADDRESS `j I
' SISERVICE CHANGE 20.00
w O o - LICENSED CONTRACTORS DECLARATION -r J •-�I"��
a u u I hereby affirm that 1 um licensed under provisions of Chapter 9 r SUANCE DATE
y z mw (commencing with Section 7000)of Division 3 of Ibe Business and - 9 € G1 ECH.
w p
H z Professions Code,and my license is in full force and effect. ❑
z o w - License Class Lic.Number ' •�,V
m - Date Contractor
Hw
QYf
¢
an w¢ OWNER-BUILDER DECLARATION I
X u y ,1 hereby affirm that 1 am exempt from the Contractor's License
MISC.- + REFER TO ORD INFORMATION
u.G¢ Law for the followingrcason.(Sec.7031.5,Buslnussand Professions pERM1T ISSUANCE - 10.00 V� VALUATION - $/FT.
I= w w Code:Any city orcounty which requires a permit construct,alter,
�jy��•
¢ ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
ea Er o a, requires file applicant for such permit to file a signed statement that TOTAL �9 PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License
Hzi La..(Chapter 9(commencing with Section 7000)ofl)ivision 3 ofthe
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
(Er o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
aim by any applicant for a permit subjects the applicant to civil penalty ALTER-DRAIN -WATER (EA.) 5.00
ofnot more than five hundred dollars($5000.) '
0 I,as owner of the Property,or my employees eRb 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 U 50.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
mentsare not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-I INC.40UTLETS 6.00
Ar
om" nt is sold within one year of completion the owner- GAS-EA.SYSTEM'-OVER 4 IEA.) 2.00 BUILDING USE
r will have the burden of proving that he did not huild or im-
for purpose of'sale.). INDUSTRIAL WASTE INTER. 30.00 IND CON PB Omer
I,as owner of the properly,am exclusively contracting with - �❑ .❑ ❑ ❑
d contractors to construct file project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6:00ASSESSORSPARCEL NO.
anrofessions Code:The Contractor's License Law does not amply
to an owner of property who builds or improves Thereon,and who LAWN SPRINKLERS-OVPAID.) 1.00 _
contracts for such projects with a contractor(,)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam cxc t n rSec, ,li.&I'.C.far this WATER HEATER W/ ,PtNT1 Kj 1'.-400
Owner Date WATER SYSTEM t 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPL'NSAl ION DECLARATION WATER TREATING E dl CuoeftlWoo
1 hereby affirm that I have a certificate of consent to self-insert, ZONING ENG.SITE NO.
or.enitificale of Workers'Compensation Insurance,or a certified
copy tltereof(Sec.3800,Lab C.). -
Policy No. - Company
O 0CertifiedcopyisberebyfernishN. FIRESPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.., REFER TO ORD. -
O Applicant Y ❑ N❑ I V ❑ N❑
CCN CERTIFICATE 01'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00/0-
LU
0.00 QLU COMPENSATION INSURANCE t PLG.CONTR. LIC.NO.
Z ('Phis sectidn need not be completed it'the permit is for one s TOTAL �J�J�OU Y❑ N❑ Y❑ N❑
bundled dollars(8100)or Icss.) I
U 0 I,certify that in the performance of the work.for which fit's par. CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to - n
0 become subject to the Workers'Compensation Laws of California. QD
y Date I Applicant ALTER OR ADD TO MECH. 5.00 BUILDING a
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z
caption,you should'become subject to the Worker'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10 C.F.M.) 4.
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOV Op00 ERM.) 6.00 SEISMIC FEE 17
(/J
I hereby affirm that there is a construction landing agency for EXHAUST HOOD (WITH DUCT) 5
the performance of the work for which this permit is issued(Sec. .t MICROFILM
3097,Civ.C.). ' HEATING UNIT(TO 100 I , ,)" 0
Lender's Name HEATING UNIT(OVER 100,000 B.T,U.)9.50 ELECTRIC
Lender's Add
ress
1 cartlfy that I have read this application and state thal the above VENTILATION FAN (SINGLE) 4.00
ialonnarioo is correct. I agree to comply with all city and county PLUMBING H.P.Or 100,000 B.T.U.) 6.00 PLUMBING S
ordinances and state laws relating to building construction, and ?a
hereby authorize representatives of this city to entm upon the BOILER-COMP IDVar 100,000 BTU)SEE FEE$CH. MECHANICALS ap
above-mentioned property for inspection pagmses. _
(We) agree to save, indemnify and,keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which O CONST.TAX
may m a e against mid City in consequence of the PERMIT ISSUANCE 10.00
gr fin
f l 5 nnitL.� O MECH.CONT, r LIC.NO. MECH.
_V TOTAL
02J' TOTAL
Si atureof Applicant_[/C or
Date •T/JA.
OFFICECOPY