11930 (2) *. .,
POST THIS CXIRDAR'FRONT OF BUILDING
NUMBER ,
y L .CtT O,F C.UPERTINO', .I � 1-1930
INSPECTION DIVISION "
n'�\ JOB INSPECTION RECORD
,J;�F'/y/ -PERMIT EXPIRATION
4 JOB ADDRESS.'./ ,Jf '1 •l'�IJNI T# ; OT#.
PERMIT EXPIRES IF WORK
OWNER CONTRACTOR, + .IS NOT,STARTEO WITHIN
INSPECTI DATE INSPECTOR INSPECTI NRECORD tgo_onvsOFPERMITIssu-
FOUNDATION Lf,b$ ��,�. &r"'C ' ANCE OR 160 DAYS FROM
LASTCALLED INSPECTION.
'LIFER
PERMIT VALIDATION
PREGUNITE c4- 647 W041-_ O• ,
POUR NO CONCRETE UNTIL AB VE HAS BEE SIGNED t
UNDERGROUND /.SLAB
PLUMBING ..
ELECTRICAL'• .. Is ANCE DAT
MECHANICAL - BLDG. LEcr, r c. CH.
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
- - INFORMATION
WOOD;FLOOR
_,VALUATION $/FT. ,
PLUMBING Z -
MECHANICAL - r
PERMIT TO ,
ELECTRICALFRAMING
- -
TYPE corvsTR.
INSULATION
-�
-J_ k/j bon
f• , OCC-GROUP RE$/UNIT$
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEE SIGNED
OtAALA
'ROOF
DIAPHRAGM
AF BUILDING USE
RES IND CON PB Otho, -
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED
•, ASSESSORS PARCEL NO.,
ROUGH _ S
PLUMBING
GAS TEST - yy TRACT No. PARCEL NO.
MECHANICAL •• - Q Td �r 4d 45z tbac7i -
'-ACC.OATE ACC•FILE NO.
ELECTRICAL - _ $.�J FINALS DATEff DATEINSP.
FRAMING �^ SAN #/,90j 2 ,ZONING ENG:SITE NO.
INSULATION 6 PLUMBING
GAS
MECHANICAL - - .FIRE SPRINK :ENERGY,T24
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED ;,HEATING N� O N0.
FLOOD ZONE A.L.U.C,.
LATH—INTERIOR .ELECTRICAL
LATH—EXTERIOR .� - + FIRE DEPT, Y'[] •N� v ❑' N�
SHEETROCK '' GRADE, ' FEE SUMMARY
SHEAR INTERIOR BUILDIN BUILDING
SHEAR EXTERIOR TEMPORA Y,APPROVALS
FIREWALLS ELECTRIC — PLAN CHECK
GAS ,R FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED JOCCUPANCY , SEISMIC FEE r
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINALISSIGNED BY BUILDING INSPECTOR; MICROFILM ,
ARRANGE FOR,INSPECTI ON BY'PHO NING 252.4505, ELECTRIC X
-� F ONE WORKING DAY BEFORE REQUIRED INSPECTION. I ' :PLUMBING ?� ' �•
i z ' . ., PLEASE GIVE JOB ADDRESS WHEN,PHONING.
SEE PERMIT FOR EXPIRATION,DATE MECHANICAL ' t '
rI IMPORTANTI CONST.TAX
PLEASE READ REVERSE SIDE BEFORE .TOTAL 1
CALLING FOR FINAL INSPECTION.
. • .. • OFFICE COPY,
APPLICANT TO FILL IN INFORMATION WITHIN. RED LINES---,- USE BALL POINT PEN ONLY
BU I L DI NG PROJECT I DENTI FICATION - PERMIT NUMBER
BUILDING
' d APPLICATION & PERMIT
AODREL! BUILDING
MECHANICAL GQ} 11930
OWNERS • � ,
PLAN CHECK VALIDATION
NAME WVr(� QTY. ELECTRIC PERMIT FEE
LDNTflacTofl's UTLETS-SWITCHES-RECEP 10.00/1.00 0�� lQ� (od
NAME . /
33 LIGHTING FIXTURES 10.00/1.00 U,
LI C.NO. _ -
FDDOFEss Tofls q1, q/ APPLIANCES-RESIDENTIAL 4.00 ��� '!
y (/ I✓��f� I PRONE-.I� 7�f"1� ' PANELS 10.00 Q F'V t DATE OF APPLICATION
PLAN CHECK FEE P.C.NO.
AOR
RCHITECT - � /,r�eJ M l,({✓�f/�rf,(/^ PANELS (OVER 200 AMP) 20.00 r
ENGINEER
sec.NO SIGNS TRANS. 3.00
ARCH:OR ENO, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
aooREss
0 1I� G GOQ lO EMP.METER OR POLE INS. 20.00 (J
A PLlCarvra -
ADDRE11 MOTORS SEE FEE SCH.
aa
0 ZG� •(� C.(�lJ'( G() 1J'(100 SERVICE CHANGE 20.00 �� BY
w o a LICENSED CONTRACTORS DECLARATION
a u u I hereby affirm that I am licensed under provisions of Chapter 9� ISSUANCE DATE
Ir' (commencing with Section.7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECN.
t' '6^ Professions Code,a my license is in full farce f ecL 'n(
z-i=m/ License Class_Lic.Number 9
o m r Dale �' �)6�� ' Contractor_ j_{1Q/k.
.Q m E BUILDING PERMIT
¢ ¢ w \ - OWNIiR-0UILDER DIiCLA RATION INFORMATION
w0 LL U 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
.. 0. Low for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
S - Code:Any city or county which req ui resa pe nn it m const not,alter,' d
S.
improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. )'1 ��
O¢ requires the applicant for such permit to file a signed statement that . TOTAL V PERMIT TO
a w m" he is licensed pursuant to the provisions of the Contractor's License
H z r
Law(Cha ter9(commencingwith Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ =$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES .TYPE CONSTR.
i by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00Q N
of not more than five hundred dollars(5500).):
❑ I,as owner of doe 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 e<
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.
1 GAS-EA.SYSTEM-11 NC.40UTLETS 6,00 W
ments are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner-
.: GAS-EA.SYSTEM-OVER 41EA.) 2.00 BUILDING USE
`"�.-••+1 builder will purpose
of burden of proving that he did not huild or im- - RES IND CON PB Omar
prove for purpose of sale.). INDUSTRIAL WASTE INTER.' 30.00
O d as owner of the property,he exclusively contracting with ❑ ❑ ❑ ❑ ❑ '
licensed contractors m construct the project(Sec. 7044,Business MI
KLERS-.1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:1'Ite Contractor's License Law docs not apply - - p -f /to an owner of property who builds or improves thereon,and woo KLERS-OVER 5(EA.) 1.00 3aWcontracts for such projects with a contractods)licensed pursuant to , TAR V-STORM EA.200ft/10.00 Qthe Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&PC.for this ER W/VENT 6.0 �''reasonOwner Date EM 5.00 �(- ACC.OATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION TING EQUIP, 5.001 hereby affirm that I have o certificate ofconsent to self-insure, ZONINGor a certificate of Workers'Compensation Insurance,or a certifiedENG.SITE NO.
copy thereof(Sec.3800.Lab.C.). g s , � - _
Policy No. Company
Q IT Certified copy is hereby furnished. FIRE BETHINK ENERGY T-24
Z Z A' Certified copy is flied with Ihr,-, in pection division.
O Applicant__ t_Ae. MISC.- REFER TO ORD. Y ❑ N❑ Y N❑
0 y CIiRTIFICATI>Oh EWMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 G FLOOD ZONE A.L.U.C.
LU >_ COMPENSATION INSURANCE PLG.CONTH, LIC.NO. PLG. ,1 p
O_ Q (This Section need not be completed if the permit is for nueTOTAL // Y❑ N❑ Y ❑ N❑
0 Z hundreddollars(S1000orless.) ,
00
I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any,manner so as to
U w become subject to the Workers'Compensation Laws of California.
BUILDING
Date Applicant ALTER OR ADD TO MECH. 5.00 (p
>_ tail NOTICE TO APPLICANT: If,after making this Certificate of Ex-
? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code„you must forthwith comply with - FEE
U such provisions or this permit Shull he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LizNDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency far EXHAUST HOOD (WITH DUCT) 5.00 Q
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.TT.U.) 8.00 MICROFILM
3097;Civ.C.). r
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
L.' I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00C, p'p
-� Information is correct. I agree to comply with all city and county PLUMBING ll�_ -�
r" ) Ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
1 / hereby authorize representatives of this city to enter upon the
+F BOILER-COMP lover too,000 BTU)SEE FEE SCR. MECHANICAL - -
1' above-mentioned property for inspection purposes.
(WB) agree to save, indemnify and keep harmless the City of MISC.,- REFER TO ORD. w
Cupertino against liabilities,judgments, casts and expenses which CONST.TAX f q
may in any way accrue against said City in consequence of the PERMIT ISSUANCE' 10.00 U ']_•�,( 9
grant of t is permit. MECH.CONT. LIQ NO. MECH
OTAL S��' TOTAL 31 j J .a
i^
Signa re of Applicant/Co actor _. Dale �
r - 'OFFICE COPY