12921 (2) POST THIS CARD NEAR'FRONfOF BUILDING,,.
CITIROF CUPERTINO . ' PERMIT NUh,RER .
• INSPECTION DIVISION
12921
JOB INSPECTION RECORD -.
'• PERMIT EXPIRATION
JOB ADDRESS 21771 Stevens Creek Blvd. . UNIT# LOT#
PERMIT EXPIRES IF WORK
OWNER Norm Hulberg CONTRACTOR ISNOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD '180 DAYS OF PERMIT ISSU(
.ANCE OR-180 DAYS FROM
FOUNDATION - -LAST CALLED INSPECTION.,;
LIFER 1
PERMIT VALIDATION '
' PREGUNITE'
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED `; r `
UNDERGROUND /SLAB, " 7
` PLUMBING _
ELECTRICALISSUANCE DA rE
ECoG. ELECT, PLGY MECH.� •
MECHANICAL
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGN EDBUILDING PERMIT
'k WOOD FLOOR .. �• i' INFORMATION
VALUATION'•,. S/FT.
.PLUMBING.
MECHANICAL " r
ELECTRICAL ;PERMIT To
FRAMING - -
•STORIES TVP[CONSTR.
INSULATION
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF SO,FT.FLOOR AREA TOTAL ACREAGE
DIAPHRAGM
. RUIED INN USE
- RES IND CON. PB OWE,
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED El,'.QoaS PARCEL No.
ROUGH.-.
PLUMBING
TRACT NO.• PARCEL NO.
GAS TEST - ..
MECHANICAL .. '
'ELECTRICAL. " FINALS DATE INSP, ?CC.DATE ACC.FILE No.
FRAMING SAN zorylNc ENG.SITE NO.
INSULATION ' PLUMBING.'
GAS
MECHANICAL• . FIRESPRINK . ENERGYT.24
V NE] V 1:1 . 411
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
FLOOD ZONE A.L,U.C.-
LATH—INTERIOR ELECTRICAL
LATH—EXTERIOR - FIRE DEPT. `'❑ IN ° ❑ N❑
` SHEETROCK GRADE FEE SUMMARY
SHEAR INTERIOR . BUILDING ..
SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING /7
.. FIREWALLS ELECTRIC PLAN CHECK' 17' `jj
' GAS - - .FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED JOCCUPANCY L
SEISMIC FEE I
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED By BUILDING INSPECTOR. MICROFILM
- y ELECTRIC -
ARRANGE FOR INSPECTION'BY PHONING 252-4505''
,ONE.WORKING DAY BEFORE REQUIRED INSPECTION., PLUMBING
O PLEASE GIVE JOB ADDRESS-WHEN'PHONING.
Z - MECHANICAL'
— SEE PERMIT FOR,EXPIRAT:ION DATE —
IMPORTANT! � CONST'',TAX ,
PLEASE READ REVERSE.SIDE BEFOREI TOTAL T'
CALLING FOR FINAL INSPECTION.
• „ •'. .. OFFICE COPY
---------------
APPLICANT TO FILL IN INFORMATION WITHIN,RED LINES - USE BALL POINT PEN ONLY
EDI LDING PROJECT I DENTI FIC PERMIT NUMBER
BUILOINGAPPLICATION & PE T . I�
/ ADDRESS 1 ((yy�� / 1
w. , aP7171 Ll
�� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 1292 1
OWNER'S PLAN CHECK VALIDATION
""ME QTY. ELECTRIC PERMIT FEE ,
PHpNE O
CONTRACTORS
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
UC.No. LIGHTING FIXTURES 10.00/1.00.
CONTRACTOR'SPPLIANCES-RESIDENTIAL 4.00
A GORES,
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECTPLAN CHECK FEE P.C.NO.
DR - PANELS (OVER 200 AMP) 20.00
ENGINEER
ilc.No. SIGNS TRANS. _3.00
AARCH,OR ODRESS ENG. SPECIAL CIRCUIT 5.00 'I PERMIT VALIDATION
'ZIP TEMP.METER OR POLE INS. 20.00 ^ ,
APPLICANTS - MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 8�
Dec . LICENSED CONTRACTORS DECLARATION s.�^^
<U U I hereby afflrm That I am licensed tinder provisions of Chapter 9 \WSSUANCE DATE
vHi i (commencing with Section 7000)of Division 3 of the Business and ,
r N z Professions Code,and my license is in full force and effect. ELECT. PLG. MECH.
z O w- License Chas, Lic.Number - ❑ ❑
0 z w Date Contractor -
a : 't BUILDING PERMIT
¢ M w - OWNER-BUILDER DECLARATION INFORMATION
w; LL y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LLO ¢ Law for the followingreason.(Sec.7031,5,Business and Professions PERMIT ISSUANCE - 10.00 -VALUATION S/FT.
m Code:Any city or county which reyuiresa permit Ioconstrucl,alter,
Q Q Q Q improve,demolish,Or rehJlf any SITUI(UtC.prior IO IIS I,SUi1RCe,aI50 ELEC.CONTR. LIC.NQ ELEC.
K requires the applicant for Such permit to file a sighed Statement that TOTAL PERMIT TO
E:
$ be is licensed pursuant to the provisions of the Contractor's License [(Q� � /
Law(Chapter 9(commencing with Section 7000)o'Division 3 of the
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
Cc r o the basis for the alleged exemption.Any violation of Section 7031.5 -STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant o a civil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500)):
❑ 1,as owner of the property,or my employees with wages its BACK FLOW PROTECT.DEVICE 4.00 OCC GROUP REs...NITS
their sole compenmtiun,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 a i owner o1' '
. properly who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5,00 SO.FT.FLOOR ARE. TOTAL ACREAGE-
hu rself or through his own employees,provided that such improve-
mentsarenolimendedorofferedforsale.If,however,lire building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will hove the burden of proving that he did not build or in, BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Othro
O 1,as owncr of.the properly,am exclusively contracti..g with ❑ ❑ _ ❑ ❑ ❑
licensed contractors to construct the project(See 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:1'Ite Conlmctor'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 contractorts)licensed purslwat In SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors license Law. TRACT NO. PARCEL NO.
❑ 1 am exempt under SCC..,IL&P.C.for Ilii- WATER HEATER W/VENT 6.00
ream
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS',COAIPENSATION :CLAR AT IO WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-inslue,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
• copy thereof(Sec.3800,Lub.CJ.
Policy No. ' Company
-
0 ❑ Certified copy is hereby furnished, FIRE SPRINK ENERGY T24
Z_ Z •❑ Certified copy is filed with lire city inspection division. MISC.- REFER TOOR D.
O Applicant _ v ❑ N❑' Y ❑ N❑
CERTIFICATI OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE .
FLOOD ZONE A.L.0 C.
W COMPENSATION INSURANCE
PLG.CONTR. LIC.No. PLG.
Z fpbis section need not he completed if the pencil Is for ore TOTAL Y C1N❑ Y❑ N❑
hundred dollars($100)or less)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
W F. - mit is issued,I shall not employ any person in any malmer so as to
O W become subject to the Workers'Compensation Laws of California.
y Dune ApplicantBUILDING d0
} m NOTICE TO APPLICANT': If,after making this Certificate of Ex- ALTER OR ADD SO MECH. 5.00
f- 2 emption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK / 37
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=C.F.M.) 4.00 -
CONSTRUCTION LENDINCAGENCY AIR HANDLING UNIT(OVER 10MC.F,M.) 6.00 SEISMIC FEE 4-0
- I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of tire work for which this permit is issued(See. MICROFILM
3097,CivC.). - -HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATI NG UNIT(OVER 100,000'B.T.U.)9.50
Lender's Address - ELECTRIC
1 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 .
ordinances and state laws relating to building construction, and BOILER:COMM 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 IOuar 100,000 BTU)SEE FEE SCH. MECHANICAL
Ot e) agree to save, indemnify and keep harmless the City of MISC. REFER TO ORD. .
Cupertino against liabilities, judgments, costs and expunses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue'againSt said City in consequence of the
ofthispermiMECH.CONT. LICNO.` MECHqTOTAL 'TOTAL 0)!!rug
alure a(App icon[/Contractor le '
OFFICE COPY