16833 (2) POST THIS CARD NEAR FRONT OF BUILDING PERMIT NUMBER
y • CITY .OF CUPERTINO 16833
INSPECTION DIVISION
JOB INSPECTION RECORD'
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PERMIT EXPIRATION
JOB ADDRESS_/�__1�2Z3 �L�V�T� UNIT# _LOT# - PERMIT EXPIRES IF WORK
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OWNER WQ y CL-2 G/_� C V, CONTRACTOR ��y\ IS NOT-STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU.
FOUNDATIONANCE OR. 180,DAYS'FROM
NOTE:'- LASACALLED INSPECTION.
UF.ER - ALL GRADING AND DRAINAGE SHALL BE INSTALLED
TO COMPLY WITH THE APPROVED PLANS AND CITY OF - '- PERMIT VALIDATION
P.REGUNITE - CUPERTINO.STANDARDS.
GARAGE SLABS - i .j 1 " ✓ "+ - -
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB
PLUMBING
ELECTRICAL - ISSUANCE DATE
MECHANICAL -' - LDG ELECT, PL 3. MECH
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR VALUATION srFT.
PLUMBING
MECHANICAL
_ ELECTRICAL _ PERMIT TO ��/� .
FRAMING - %— `^T
Rev-
INSULATION STORIES TVPE DONSIR
OCT GROUP RES UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
SO IT,FLOOR AREA TOTAL ACREAGE
ROOF NOTE:NO FINAL INSP.SHALL BE MADE BEFORE -
DIAPHRAGM
THECONSTRUCTION TAX IS PAID
RuanwN use
ROOF SHEATHING NES IND CON PB OP-
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP, ❑ El ❑ El ElASSESSORS PARCEL NO
ROUGH SANA
PLUMBING - ELECT.ENERGY
TUBS&SHOWER PAN PLUMBING ENERGY TRACTNO PARCEL NO
MECHANICAL VECH ENERGY.
.
ELECTRICAL BUILDING ENERGY ACCDATE ACC FILE NO
FRAMING ELECT.FINALITEST
ZONING ENG,SITE NO.
INSULATION - PLUMBING
GAS TEST I GAS
MECHANICAL FIRE SPRINK ENERGY T 24
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y E] •"❑ ° ❑. NE]
FLOOD ZONE AL UC
EXTERIOR SHEAR. ELECTRICAL RELEASE
INTERIOR SHEAR FIRE DEPT, Y E] "❑ ° L7 "❑
SHEETROCK GRADE FEE SUMMARY
EXTERIOR LATH BUILDING
INTERIOR LATH TEMPORARY APPROVALS BUILDING
SCRATCH COAT - 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 ISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC !
I U.) 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.
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NO PROJECT I DENTI FICATION - gPERMITNUMBER
aolLolNo /� /ArsC� APPLICATION & PERMIT �.��-
ADDRESS ro .23 ' A„
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
�/��pt!'n!!.� Dtvc-z.�,p�/e Ni PLAN CHECK VALIDATION
NAME
I' _ DTV. ELECTRIC PERMIT FEE
PHONE,2'/(, OC
CONTRACTORS
NAME J7rIV/OG•:vD D�`y«Oi+t4-e� OUTLETS-SWITCHES-RECEP 10.0011.00
rj LIC.NO. LIGHTING FIXTURES 10.00/1.00
ADDRESS TOR's 3(000 (leo/N�/�'Y.0 I}- APPLIANCES-RESIDENTIAL 4.00
I:zPHONE PANELS 10.00 DATE OF APPLICATION'
OORRC TECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARC..SS ENG. PERMIT CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS
MOTORS SEE FEE SCH.
• ytL SERVICE CHANGE PA1 .00
0¢z
r
00 LICENSED CONTRACTORS DECLARATION
a v I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE '
N a w (commencing with Section 7000)of Division 3 of the Business and LOG. ELECT. PLG. MECH.
H N z Professions Code,and my license is in full force and effect ❑
z O m- License Class Lic.Number
0 Date El Lmrt E:Contractor City of Cupertin
a r 5 BUILDING PERMIT
¢ ¢a OWNER-BUILDER DECLARATION INFORMATION
w ; w I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
u coo ¢ Law for the following reason.(Sec.703 1.5,Businessand Professions PERMIT ISSUANCE ,10.00 Z.d U' VALUATION $/FT.
5 - J Code:Any city or county which requires permit to construct,alter,
ELEC.CONTR. LIC.N0.
i[ ¢ ¢ E, improve,demolish,or repair any permit
structure,prior to its issuance,also ELEC. '1 Z,
¢ requires the applicant for such permit l0 file a signed statement IIwI TOTAL .[..
e w u he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
Fzi
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 a Business and Professions Cade)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE eV�
¢ H m the basis for the alleged exemption.Any violation of8ection 7031.5 STORIES TYPE CONSTR.
a 3 .- by any applicant for a permit subjects the applicant Ica civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).1:
❑ 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 nffc.d 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 hnlld5 or Improve,lherlon,and who does such work FIXTURES-PER TRAP 5.00 SQ 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-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or an. BUILDING USE
RES IND CON PB Other
prove for purpose of the.), INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
❑ d as owner of the property,ant project
(Se contracting with
licensed contractors od . f construct the project La 7044, Rosiness LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Con tractor's License Law Joos not apply
t0 ancontracts
owner of property projects with
builds tr improves Insect pu and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
tele Contractor's
LcenLwithuuontructm(sl licensed pursunitt to SEWER-SANITARY-STORM EA.200ft/10.00
the ContraCfoi i LICCa,I'Law. TRACT NO, PARCEL N0.
❑ I am exempt under Sec..,B&P.C.for this WATER HEATER W/VENT 8.00
reason
Owner Dam WATER SYSTEM 5.00
ACC.OATE ACC.FILE NO.
WORKI!RS'COMP1iNSM ION DFCLARA'I'ION - WATER TREATING EQUIP. 5.00
I hereby affirm that I have a cerhl'iune ofconsent to self-Insure, ZONING ENG.SITE NO,
or a certificate of Workers'Compensation Insurance,Or a certified
copy thereof(Sec.3800,GIb.C.).
Policy No. Company
0 ❑ Certified copy is hereby furnished' FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC. REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ N❑
= �+ PERMIT ISSUANCE 10.00
W - C17 R1 FICAT'1i 01°EXEMPTION ION ION PROM WORKIiRS' FLOOD ZONE A.L.u.C.
W > COMI'IiNSAT'ION INSURANCE PLC,CONTR. LIC.NO. PLG.
CL CL Z (This section need nor be Completed it'the permit is for one TOTAL Y F] N❑ Y ❑ NF]N
hundred dollars(S 100)or Ies0
U O I certify that in the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
•LL U mit is issued,I shall not employ any person in any manner,o as m
become subject to the Workers'Compensalion Laws of California.
y Dam Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,alter making Ihi,Certificate DIlix-
I•" ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK -
provisions of the Labor Code, you most fooliwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=11F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.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,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC ZE V 0
1 certify that I have read this application and slam that the almve 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-COMP(3 H.P.or 100,000 B.T.U.) 6.00
.40 hereby authorize representatives of this city to enter upon the
above nsenrimod property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep h rnsless the City of MISC.- REFER TO ORD.
Cupertino against liahilities,judgments, costs and expenses which CONST.TAX
ay in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
ming of this P omit MECH.CONT. LIC.NO. MECH.
- * � / _ TOTAL TOTAL �-a • D
Signature ofA licamicco me r Date
OFFICE COPY