12854 (2) POST THIS CARD NEAR FRONT OF BUILDING
• I` Nil NUMBER
CITY OF VERTINO 1285
INSPECTION DIVISION
JOB INSPECTION RECORD
^y �/ PERMIT EXPIRATION
JOB ADDRESS v V # - _LOT#
PERMIT EXPIRES IF WORK
OWNER CONTRACTOR IS NOT STARTED WITHIN
INSPECTION DATE I INSPECTOR INSPEC I N RECORD 180 DAYS OF PERMIT ISSU,;
FOUNDATION - ANCE OR 180 DAYS FROM '
' UFER
LAST CALLED INSPECTION.
NELECTRICAL
PihM( DATION
UNTIL ABOVE HAS BEEN SIGNED FEB 2 3 �9$�
GROUND /SLAB r
��I
- CkO} Cupertino
ISSUANCE DATE
u ELECT. PLG. ' MECRI
L ❑ ❑ ❑ `
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
WOOD FLOOR - INFORMATION
PLUMBING - - wA LunnDrN, $/FT.
MECHANICAL
1 r.
ELECTRICAL - yam. PERMIT TO
7
FRAMING -
INSULATION STORIES TYPE CONSTR.
OCG GR UP RES.UNITS
_
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF IO.FT FLOOR AREA TOTAL ACREAGE
DIAPHRAGM. _
OUIL USE
CON _
RE IND CON PO OIImr
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑ ❑
ASSESSORS PARCEL NO.
ROUGH
PLUMBING '
GAS TEST _ TRACT No. - PARCEL NO.
MECHANICAL
ELECTRICALFINALSo DATE INSP. .^c,c.DATE ACC.FILE No.
FRAMING SAN #
INSULATION - - PLUMBING ZONING ENG,SITE NO.
GAS
MECHANICAL FIRE SPRINK ENERGY T 24
COVERAO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y❑ N0 Y ❑ N❑
LATH-INTERIOR' ELECTRICAL FLOOD ZONE A.L.U.C.
LATH-EXTERIOR FIRE DEPT. Y❑ N❑ I Y N❑
SHEETROCK. - GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING l ` .
SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING 1�! '•
FIREWALLS ELECTRIC PLAN CHECK
GAS - FEE j
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCYOF BUILDING ISNOTPERMITTED UNTILBUILDING FINAL IS SIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
0� ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
Z PLEASE GIVE JOB ADDRESS WHEN PHONING.
-'SEE PERMIT FOR EXPIRATION DATE - MECHANICAL'
IMPORTANT! CONST.-TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICECOPY
' I
P APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
aDBU I LDING PROJECT I DENTI FICAT APPLICATION & PERMIT
N PERMIT NUMBER
I TNG -
AD �� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 12854
OWNERR'a - PLAN CHECK VALIDATION
OTY. ELECTRIC PERMIT FEE
PHONE
coNreacroR OUTLETS-SWITCHES-RECEP 10.00/1.00
7e
LIC.N LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S PPLIANCES•RESIDENTIAL 4.00
a00RE55
Q PHONE 0S37 PANELS 10.00 DATE OF APPLICATION
ARC.IPC.rtPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
LID.No. SIGNS TRANS. 3.00
ADOHESs ENG. SPECIAL CIRCUIT 5.00
NEWMWLIDATION
ZIP TEMP.METER OR POLE INS.TEB '2 20.00 a, 1997
APPLICANT MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 ,,
o O LICENSED CON'TRACT'ORS DECLARA'T'ION �!Of Cupertino
Q U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
wz "' ro omencing with Section 7000)of Division 3 of the Business and
Q o. R D ELECT. PLG. MECH.
H 7 i rofessions Code,a Sd m icense is in full force and effect. ❑ El 1:1z o y License ass Lie.Number
O m H w Doo
Contractor Bh
a m f BUILDING PERMIT
IC w OWNER-BUILDER DECLARATION INFORMATION
w ;a- N 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
u o< Law for the following reason.(Sec.7031.5,Businessxnd Professions VALUATION $/FT.
� yo Code:Any city or County which requires a permit to co-0n.", Ie,a PERMIT ISSUANCE 10.00 /
rt ¢ ¢O improve,demolish,or repair any structure,Prior m its issuance,also ELEC.CONTR. LIC.NO. - ELEC.
G u requires the applicant for such permit to file a signed statement that TOTAL ' PER TO
E
2 w he is licensed pursuant to the provisions of the Contractor's License
z ¢ Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe I
i o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
X I_$ the basis for the alleged exemption.Any violation of Section 7031.5 ST RIE TYPE CONSTR.
n ; by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN& VENT-WATER IEA.) 5.00
of not more than rive 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,AR EA,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 SO.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-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA ) 200
builder will have the burden of proving that - . - . .
he did not build or im- BUILDING USE
prove for purpose of sale J' INDUSTRIAL WASTE INTER. 30.00 IND CON Pe Omer
D 1,as owner of the property,am exclusively contracting with ❑ 1:1 ❑ El
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 1 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 IEA.) 1.00
contracts for such projects with;I contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec..,BARC.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a Certificate ofconsent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. ompany
O O CCrtlriedC�WryIs hereby FIRE SPRINK ENERGY T24
ZZ etion division. MISC- REFER TO ORD.
O pplic,al Y❑ N❑ Y E) No
to PERMIT ISSUANCE 10.00
cc - .R tlC :OP EXEMPTION FROM WORKERS' FLOOD ZONE A.L.U.C.
W 1 OMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
j0 (This Section need not be Completed if the permit Is for one TOTAL Y N� Y [:] NC3
hundred dollars IS 100)or TCR.)
U O 1 certify that in the performance the work I. whi is per- TY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F Mit is issued,1 shall mol employ person y n•
U w becolDT su c [ Workc .o alio
n Dala s- he ALTER OR ADD TO MECH. 5.00 BUILDING
} y NOTICE TO APP (CANT: If after m: g This Cert ific t• (Ex
F 2 emption,you should becom bjecl the this Com •nsalion APPLIANCE 5.00 PLAN CHECK 2
provisions of the Labor C e, ya must forthwith comply with FEE
U such provisions or this Peru
shall a deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M.) 4,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 111000C.EM.) 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. MICROFILM
3097,CP.C.I. HEATING UNIT(TO 100,000 B.T.U.) 8.00 _
Lender's Name
Lender's AddreHEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
ss
I certify that l have read this application and state that 0n above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and countyPLUMBING
ordinances and state laws relating m andbuilding construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP IQVar 100.000 BTU)SEE FEE$CH. MECHANICAL
(We)'agree to save, indemnify and keep harmless the City of MISC.• REFER TO ORD.
Cupertino a .red liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in ay accrue against ity in sequence of the
grantin of is permit MECH.CONT. LIC.NO. MECH.
Izl -." TOTAL TOTAL
of App' a onlractor Date l
OFFICE COPY