12410 (2) POST THIS CARD.NEAR FRONT OF BUILDING
-PFRMIT NUMBER-
i ',CITY..0F 'CUPERTINO, i ia1
INSPECTION DIVISION "
JOB INSPECTION,RECORD
•�' • PERMIT EXPIRATION
' JOB ADDR ESS 'UN " _LOT# PERMIT,EXPIRES IF WORK
'. OWNER CONTRACTOR - +' , • ,IS.NOT STARTED WITHIN'
INSPECTION IJATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION ANCE OR 180 DANS FROM
LASTCALLEDINSPECTION. '
LIFER
' n P•REGUNITE - - - PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB'
PLUMBING
ELECTRICAL - - - ISSUANCE OnrE
MECHANICAL - _ BLDG. ELE.T. PLG:. -IECH.•
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BU I DING PERMIT
I FORMATION
WOOD FLOOR VALUATION $/FT.
PLUMBING _ - .:..0 A ,, r0
,MECHANICAL 'ELECTRICAL PERM
- PERM, T '
FRAMING
INSULATION -STORIES rvP oN$TR.
.. , OCC.GROUP RES.UNITS,
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
a ROOF "SO FLEEOOR AREA TOTAL ACREAGE
DIAPHRAGM "+ - , _ BUILD NO uSE
_ .. HES IND PIT ome,
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED . El'
. ROUGH - - Assess HS PARCEL NO.
• PLUMBING - _ • '
GAS TEST, - - .. TRACT NO, PARCEL NO.
MECHANICAL ' -
ACC.DATE. ACC.FILE N0.
'
ELECTRICAL FINALS DATE 'NSP.
'. FRAMING '( SAN # - -
INSULATION -
ZONING ENG.SITE NO.
PLUMBING.
.'y.
• r GAS � �•
MECHANICAL, EIRE SPR,NKENERGY.TSA
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED_ HEATING Y "0 ` NEI
'LATH—INTERIOR , -� , ELECTRICAL FLOODZONE A:D.U.C.-
Y❑ Np' ,'
Y'
o No
'LATH-EXTERIOR - FIRE DEPT.
SHEETROCKv GRADE;, FEE'SUMMARY
SHEAR INTERIOR _ BUILDING . -' -
• SHEAR'EXTERIOR n TEMPORARY APPROVALS ' BUILDING % .1 'r "-
FIREWALLS' - _ ELECTRIC '" ;f„ . •.PLAN'CHECK '
• - GAS.. ... - :.FEE - -NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE , D „_
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED'BY'BUILDINGINSPECTOR.. ' '
• � r'M ICROFILM -
-ARRANGE'FOR INSPECTION'BY PHONING 252-4505, ELECTRIC, ry,
o� ONE WORKING DAY .BEFORE REQUIRED'INSPECTION:• PLUMBIyG
PLEASE'GIVE JOB ADDRESS WHEN PHONING.
' Z , —.,SEE PERMIT FO.R EXPIRATION DATE„ Mecr riNIDAL ,
CONST.TAX
IMPORTANT' R� ,a
PLEASE.READ REVERSE SIDE BEFORE i" " °. TOTAL
CALLING FORTINAL INSPECTION. :"
. - OfFICECOPY,'. --
APPOCANT TO FILL IN' INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER
MTLmNG APPLICATION & PERMIT
AnoREss
•'"1?n C�� le BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 12410
PLAN CHECK VALIDATION
OTY. ELECTRIC PERMIT FEE I ''
PHONE
CONTRACTORS' '
AMEUTLETS--SWITCHES-RECEP 10.00/1.00
Tic.No LIGHTING FIXTURES . 10.00/1.00
CONT ATOcroRa
ADDRESAPPLIANCES-RESIDENTIAL 4.00 -
J SI`UC�I PHONEf �'.� (�f PANELS 10.00 DATE OF APPLICATION
ARCHITECi-�s PLAN CHECK FEE P.C.NO.
on In �{(`(�'1l7 .1d 0(�. PANELS (OVER 200 AMP) 20.00
ENGIN
.LIE.N . I SIGNS TRANS. 3.00
ARCH.OH ENG. PERMIT VALIDATION
Ao F s SPECIAL CIRCUIT 5.00
TEMP.METER OR POLE INS. 20.00
APPLICANTS - MOTORS SEE FEE SCH.
aooREgss.� �
Op- ,(- - Q,�, j-y'1(vQ SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION ' y 9 r O
< Et u I hereby affirm that I am licensed under provisions of Chapter 9 '% 11SS ANCE DATE
a "' (Cnmmet{cing h Section 7000)of Division 3 1 lime, and BLDG. EL PLG. MECH.
- w w Professions Co nye ry license is in full fore p O
z o w Licens s �Lia Number _ p y ❑ ❑
0 r Dale Contractor D((1[�- C�
Y E BUILDING PERMIT
a ¢ w u OWNIiR-BUILUIiR DECLARATION INFORMATION
F.
O u H 1 hereby affirm that I um exempt from the Contractor's License MISC.- REFER TO ORD
3 0 y y P VALUATION $/FT.
HtZ_ 0 ¢ Law for the following reason.(Sec.7031.5,BusinessanJ Professions PERMIT ISSUANCE 10.00 /C ,A
Code:Any city' or county which requires u permit to construct,alter, T / li 'i `''
to¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. r
0 u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w$ he is licensed pursuant to the provisions of lite Contractor's License
Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe i/MBQA0,__ 1,-1,7/2✓✓
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
W 1- the basis for the alleged exemption.Any violin ion of Sechon 7031.5 STORIES TYPE CONSTR.
i_: any applicant for a permit subjects the applicant to a civil Penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).1:
❑ I,as owner of the property,or my employees with wagesas BACK FLOW PROTECT.DEV ICE 4.00 OCC.GROUP REB.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
Cade: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-
mentsarenotintendedoroffered for sale.ll',however,the building 'GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 6.00
of improvement is sold within one year of completion,the owner- GAS EA.SYSTEM-OVER'4 IEA.) 2.00
builder will have the burden of proving that he did not build or int- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ -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 PARCECNO.
and Professions Code.The Contractor's License Law dues 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 contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
Ilse Contractors License Law. TRACT NO. PARCEL N0.
❑ lam exempt under Sec,.,B.&P.C.for this WATER HEATER WIVENT - 6.00
reason
Owner - Date - WATER SYSTEM '5.00 ACC.DATE ACC.FILE NO.,
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I herebyraffirm that I have a certificate ofconsent to self-insure, ZONING ENG.SITE NO.
or a certificate of Worksers'C m $lion Insurance,or a certified
COPY Ther• (S{•a,s�90�J,e / -yf�n�v JJ
Policy No� Cotnpaty-IA �1eeh)Ffltn 'rn
0 Certlfie copy IIsi by furnished - FIRE SPRINK ENERGY T-24
[Certifi c I file nth the II'y I sec ' division.
Z'ZO}` A ficanl c -(,� (�1�"}� MISC.- - REFER TO ORD. Y ❑ N❑ Y ❑ N❑
~ w Nato 1 1W__ PERMIT ISSUANCE 10.00
cc - CF:RT - ATE OrEXEMPTION FROM WORKERS' FLOOD ZONE A.L.U.C.
L COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
4• (This section need nut be canmleled if the permit is for one TOTAL Y❑ ,N❑ Y❑ N❑
Z bund red dollars(5100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
L F mit is issued', I shall not employ any person in any manner so as to
U become subject to theWorkers'Compensation Laws of California. -7
y Date Applicant ALTER OR ADD TO MECH. 5.00 �� LP
} N NOTICE TO APPLICANT: It,after making this Certificate oFET BUILDING
,
F ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the'Labor Code, you must forthwith comply with
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00 FEE
CONISTRUCTION LENDING AGLNCY AIR HANDLING UNIT(OVER IO,000C.RM.) 6.00 SEISMIC IFEE 3 O�
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,Civ.C.). a HEATING UNIT(TO 100,000 B.T.U.)- 8.00
Lender's Name
Lender's Add, HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
ess
• I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
informa
tion is correct. I agree to comply with all-city and County PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby aulhorize'representut rues of this city to enter upon the BOILER-COMP love,too,000 BTU)SEE FEE SCH. - MECHANICAL
above-mentioned-property for inspection Purposes.
(We) agree to Salve, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, casts and expenses which -. .• CONST.TAX
may in y w y accrue against sai i In consequence of the PERMIT ISSUANCE 10.00
grantin Ihi ¢roil MECH.CONT. LIC.NO. - MECH.
TOTAL
I��(/Ll 6 J J _ TOTAL �'� Or.
SignaabM,-or-ApPlicant/Contractor Date
- OFFICE COPY