13080 POST THIS CARD NEAR FRONT OF BUILDING
• ;PFRM IT.NUMBER'
CITY OF -CUPERTINO 13080
INSPECTION DIVISION.
JOB INSPECTION RECORD
�• PERMIT EXPIRATION
11065 LA PALOMA - I
JOB ADDRESS UNIT# LOT#
PERMIT EXPIRES IF WORK
OWNER DON MACKENZIE CONTRACTOR IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
ANCE OR 180 DAYS FROM
FOUNDATION v � OR
�'� LAST CALLED INSPECTION. -
UFER
PRE6UNITE PERMIT VALIDATION
a a
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB
PLUMBING - /Y
ELECTRICAL . ISSUANCE DATE .
MECHANICAL _ - LR'; �� LBL'DG I IELECT, PLG. - MECH.
El. ❑ ❑ N
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT'
_ INFORMATION
WOOD FLOOR VALUATION siFT.
PLUMBING -
MECHANICAL -
ELECTRICAL. PERMIT TO- - -
FRAMING -
STORIES ' TYPE CONSTR.
INSULATION -
I�y ev oa- ou oYC +5=10'$8c
az-4f-7 OCC:GROUM RES.UNITS
-PLACE NO SURFLOOR UNTIL ABOVE HAS BEEN SIGNED1.2 -21147 0
TOTAL ACREAGE
ROOF
i1 DIAPHRAGM
BUILDING USE
IND' CON PB O,hr•
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED
ASSESSORS PARCEL NO.
ROUGH
PLUMBING .,T
TRACT NO. PARCEL NO.
GAS TEST - Z ✓
MECHANICAL
ELECTRICAL FINALS DATE INSP. ACC.DATE ACC FILEND -
FRAMING, 2- SAN # ZONING ENG.SITE NO!-
INSULATION PLUMBING. ` a \
GAS ....
/� FIRE SPRINK ENERGY T-2C
MECHANICAL —J— l
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED I HEATING -° ❑ " N❑• Y ❑• N�
FLOOD ZONE ALU.C.
LATH-INTERIOR ELECTRICAL -�-
LATH-EXTERIOR FIRE DEPT. Y F] No Yo N[]SHEETROCK 2 6- E GRADFEE SUMMARY
SHEAR INTERIOR BUILDING BUILDING
SHEAR EXTERIOR - TEMPORARY APPROVALS
FIREWALLS - ELECTRIC PLAN CHECK
F
GAS EE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY - SEISMIC FEE I
OCCUPANCY OF BUILDING ISNOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, . ELECTRIC
F , ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING „ <_
Z -• O� PLEASE GIVE JOB ADDRESS WHEN PHONING.
' MECHANICALS- SEE PERMIT FOR EXPIRATION - ,
IMPORTANT!
CONST:rnx
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
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 3�8�
DDRESS BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
/ Db � z=tq
OWNERS PLAN CHECK VALIDATION
E A'-I i AL QTELECTRIC PERMIT FEE 3 7 (�
• ��I�C.oEAI LIC vIIONE Y. _. -_
CONTRACTOR S7
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00 GZ
LIC.No. LIGHTING FIXTURES 10.00/1.00 fj
CONTRACTOR'S
ADDR Ess PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER tt
• LIC.No. SIGNS TRANS. 3.00 �pl
ARCH.OR ENG.' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS -,
ZIP EMP.METER OR POLE INS. 20.00 +I
APPLICANT'S MOTORS SEE FEE SCH. /`^'(�,��.af.A ,
ADDRESS � -- w '-
SERVICE CHANGE 20.00 - /)A!�.Ly - vsP�rd1�
woo LICENSED CONTRACTORS DECLARATION /C)i /
rt I hereby affirm that I am licensed under provisions of Chapter 9 SUANCE DATE
H z w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
e- i Professions Code,and my license is in Cull force and effect- '
z 0 '� - License Class Lic.Number r ®.
9 °w Date Contractor '
rt rt w < OWNER-BUILDER DECLARATION �h:nt� BUILDING PERMIT
u ^'j�t 'R EFER'TO ORD INFORMATION
wu H I hereby affirm that I am exempt from the Contractors License MI$D.- JHS VALUATION S/FT.
.. 0 a Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00 CG-�
E m I Code:Any city or county which requiresa permit to construct,alter,
ce BE Q 0 Improve,demolish,or repair any structure,prior to its issuance,also ELEG CONTR. LIC.NO. ELEC. -7
O BE requires the applicant for such permit to file a signed statement that TOTAL�Q / PERMIT TO
n w m LL he is licensed pursuant to lire provisions of the Contractor's License "�
ur z < Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe 44�/%LCN
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ E0 the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
e. by any applicant forapennit subjects the applicant mucivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
ofnot more than fivehundmd dollms(S500)J: � ��
O 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 n
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 /� 3 /
_ Code:The Contractors 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.RLooR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsare not
intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00 U
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
bur r will have the burden Of proving that he did not build or im- RES IND- CON PB Other
Pro for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
nsem
I,as owner of the property,aexclusively contracting with El El 1:1 ❑
li d contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
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 contractorts)licensed pursuant to
SEWER-SANITARY-STORM EA.200ft110.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ 1 am exempt under 'ec. B.&P.C.Cor this WATER HEATER W/VENT 6.00
as
Owner 67110-3(�2:a WATER SYSTEM 5.00 ACG DATE ACO.FILE NO,
WORKF-RS'COMPENS TION DECLARATION WATER TREATING EQUIP. 5.00 '
I hereby affirm that I have a certificate of consent to self-insure. -
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.). ^'ir nr fi!IIr1Prttnn
Policy No. Company
O ❑ Certified copy ishemby furnished. FIRESPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. Y N y N
Q Applicant ❑ ❑ ❑ ❑
� y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 V � FLOODZONE A.L.U.C.
LLI > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. /_ y❑ N❑ v❑ N❑
d O (This section need not be completed if the permit is for one TOTAL (.
Z hundred dollars(S100)or less.)
•U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
k,_ H mit is issued,I shall not employ any person in any manner so as to
Uw become subject to the Workers'Compensation Laws of California. BUILDING +�
Uate Applicant ALTEWOR ADD TO MECH. 5.00
} to NOTICE TO APPLICANT: If,after making this Certificate of Fx-
F ? emplion,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=C.F.M.) L00
V CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.FM.) 6.00 SEISMICFEE '
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work Cor which this permit is issued(Sec. MICROFILM
3097,CmC.L + HEATING UNIT(T0:10Qp0(F..B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC Q
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 �� v
• 'ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon theBOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL ��✓
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs,and expenses which CONST.TAX
May in any way ac rue against said City in consequence of the PERMIT ISSUANCE 10.00 ��
Ming ofts -rmi . MECH.CONT. LIC.NO. TOTAL YN
_ /� - TOTAL
Sig um o Applicant) ont actor Dale
t, OFFICE COPY
r