12470 (2) POST THIS CARD NEAR FRONT OF BUILDING
PERMIT NUMBER
CITY OF CUPERTINO 12470
INSPECTION DIVISION
JOB INSPECTION RECORD ^� l
. PERMIT EXPIRATION
JOB ADD SS UNIT _54? OT#
PERMIT EXPIRES IF WORK
OWNER coNTR Ac1OR - IS NOT STARTED WITHIN ,
INSPECTION DAT INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
ANCE OR 180 DAYS FROM
FOUNDATION _
LIFER LASTCALLED INSPECTION. I•
PREGUNITE
PERMIT VALIDATION
'
J
r �
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB
PLUMBING C
ELECTRICAL - +'•• ISSUANCE DATE
MECHANICAL SLUG. ELECT. I PLC, MECH.
❑ ❑ ❑ ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED - BUILDING PERMIT
WOOD FLOOR INFORMATION
PLUMBING VALUATION ,.q $/FT.
MECHANICAL: '
ELECTRICAL PERMIT TO
FRAMING
STORIES TYPE CONSTR.
INSULATION
OCC,GROUP RES.UNITS ,
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
SOFT,FLOOR AREP TOTALACREAGE
ROOF
DIAPHRAGM
aUILOI USE
' .. HE'SS IND CON ON Pa Otl,e,
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑ ❑ ❑
ASSESSORS PARCEL NO.
ROUGH
PLUMBING
GAS TEST TRACT NO. PARCEL NO
MECHANICAL
,
ELECTRICAL FINALS DATE INSP. ACCDATE ACC.FILE NO.
FRAMING SAN #
ZONING ENG.SITE NO.
INSULATION PLUMBING - •
GAS
. MECHANICAL Fl RE SPRINrc ENERGY T44:,
'COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
FLOOD ZONE. A.L.U.C.
LATH—INTERIOR ELECTRICAL
LATH—EXTERIOR FIRE DEPT. `'❑ N❑ Y ❑ rv❑
SHEETROCKGRADE FEE SUMMARY
SHEAR INTERIOR , BUILDING U BUILDING" T
SHEAREXTERIOR TEMPORARY APPROVALS
FIREWALLS ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED,BY BUILDING INSPECTOR. MICROFILM
w�
ARRANGE FOR INSPECTION BY PHONING M-4505, ELECTRIC 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 f
CALLING FOR FINAL INSPECTION.
OFFICECOPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
x BDILDING APPLICATION & PERMIT 12470
ADDREsS
.In at BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
e
OWNIERS PLAN CHECK VALIDATION
N" xSi i S
OTY.• " ELECTRIC PERMIT FEE n p
�esf"e PHDrvE Z7--/(
ory RACTOR's OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
Y eo Ar Serviot_C D 3 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S Ir� l,�
ADDRESS af .. APPLIANCES'-.RESIDENTIAL 4.00
'NwI Fie y10 A, �f #vv 1, PHONE 7'-`fZ7 - PANELS •10.00 DATE OF APPLICATION
ARCHITECT - PANELS (QV MPI 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRAN . 3.00
AR SS ENG. - - SPECIA T 5.00 PB[Ipr!{VALIDATION
AOORESS MSV
ZIP EMP.M E 019 r.IL S. 20.00
APPucarvrs - MOTORS SEE FEE SCH. PR P.ADDRESS ✓1 (/
• " SERVICE 20.00
.. ::J
woo LICENSED CONTRACTORS DECLARATION lj1YV Qf CUn• t n0
¢v I hereby affirm that I am licensed underprovisio rs of Chapter 9 ISSUANCE DATE
v, a N (commencing with Section 7000)of Division 3 of the Business and BLDG., ELECT'. PLG. - MECH.
r D z Professions Code,an )y license is in full for •an ffec
z O m Licensc as F�—.'Lia Number3 ❑'
2 Contractor
a Y E d - BUILDING PERMIT
¢ w¢ OWNER-BUILDER DECLARA'T'ION -
w 3 u w I hereby affirm that 1 am exempt from the Contractor's License MISC.- REF ER TO ORD INFORMATION.,
LLC ¢ Law for the following reason.(Sec.,7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
H - w Code:Any city orcounty which requires a permit to construct,alter, 0 ^—
Q Q Q Improve,demolish,Or repair any structure,prior to its Issuance,also ELEC. LI
CONTR. C.NO. ELEC. p�
- O u requires the applicant for such permit to file a signed statement that TOTAL O�-L/ PERMIT TO
wre he is licensed pursuant to the provisions of the Contractor's License
H z r Law(Chapter 9(commencing with Section 7000)of Division 3 oflhe - a
¢ Business and Professions Code)or that he is exempt therefrom and OTY. n - PLUMBING PERMIT ' FEE l
¢ = the basis for the alleged exemption.Any violation of Section 7031.5 t • ` W STORIES TYPE CONSTR.
d ; - by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500)-)'. '
❑ 1,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[hereon,and who does such work FIXTURES-PER TRAP 5,011 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or,through his own employees,provided that such improve-
.cats are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 (EA) 200
builder will have the burden of proving that he did not build or im - . . .
BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER . 30.00 RES IND CON PB Other
C] .1,as owner of the property,am exclusively contracting with ❑ ❑ "❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS V.B. 6.00 ASSESSORS PARCEL NO.
T 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 contracloGs)licensed pursuant to SEWER-SAN T B11 Oft/10.00
_ the Contractor's License Law. TRACT NO, PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dale _ WATER SYSTENCjt Of Upe 1 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 :5-
1 hereby affirm that 1 have a certificate ofconsent to self-Insure, I -
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO,
copy lhercof(Sec.3800,Lab.Cgp- � (�.��f
Policy No. Company_TE3R[CMn/ AFH LAS
Q ❑ Certified copy is hereby furnished, - FIRE SPRINK ENERGY T 24
❑ Certified..FFoy is yle with tppe city"ins ectmo division.
Z O� Applicant $17� Sa�cPI 2e V MISC.'- REFER TO ORD. Y❑1• N❑ Y ❑ N❑
CCw PERMIT ISSUANCE - 10.00 V FLOOD ZONE A.L.U.C.
LU CERTIFICATE COM E EXEMPTION FROM WORKERS'
W �_ � COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG, s�-
CL 0 (This section need not be completed if the permit is for one TOTAL �sf Y,❑ N❑ Y❑ N❑
0 2 hundred dollars IS 100)or less I I I I I -
U O 1 certify that in the performance of the work for which this per- QTV= + MECHANICAL PERMIT a FEE FEE SUMMARY.
IL 1- mil is issued,I shall not employ any person in any mariner so as to y„
U become subject to the Workers'Compensation Laws of California.
U ad Date Applicant BUILDING
a - ALTER OR ADD TO MECH. - 5.00
�- m NOTICE. TO APPLICANT: If,after making this Certificate of Ex-
Z_ 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 10,030C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000OFM.) 6.00 SEISMIC FEE
1 herebyaffirm 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,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC 020
Lender's Address
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct.1'agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H:P.Or 100,0008.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes. _
(We) agree u.-Save, indemnify and keep harmless the City of MISC.-- REFER TO ORD.
Cupertino against liabilities,judgments, Costs sad expenses wider CONST.TAX
may in any way,accrue against said City in consequence of the PERMIT ISSUANCE' 10.00
granting of this permit. - MECH.CONT. LIC.NO. MECH.
7 TOTAL TOTAL
nature o Ap an[/Contraomr Date -
OFFICE COPY