12522 POST THIS RD NEAR FRONT OF BUILDING
PFHMI12522
INSPECTION CIOF CUPERTINO
INSPECTION DIVISION
/�ny JOB/INSPECTION BREI/COORD
PERMIT EXPIRATION
JOB ADDRESS
1`� '/ l0UT/11NIT# LOT#
PERMIT EXPIRES IF WORK
OWNERCONTRACTOR
IS NOT STARTED WITHIN
INSFfECTION DATE I IN§PtCTOR - INSPE ION RECORD 180 DAYS OF PERMIT ISSU-
ANCEFOUNDATION - Q(i�@Q4AVS FROM
LAST SPECTION.A
LIFER„
PREGUNITE APPARM9 - J�7 VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED C6 Of Cppetm,
UNDERGROUND /SLAB '
PLUMBING
q:
ELECTRICAL ISSUANCE DATE
MECHANICAL
BL ELECT. PLG. - MECH.
-
❑ ❑ ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR FSTORIES
SIFT.
-
PLUMBING -MECHANICALELECTRICAL MITTFRAMING -' TY CONSTR.
INSULATION � � RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
SO,FT.FLOOR AREA TOTAL ACREAGE
ROOF
DIAPHRAGMS BUILDING USE
RES INDPB Olde,
C
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED � El
ASSESSORS PP CEL NO. /
ROUGH
PLUMBING
GAS TEST rFACT NO. PARCEL NO.
MECHANICAL
ACC.DATE ACC.FILE NO.
' ELECTRICAL FI A DATE INSP. '
FRAMING - SAN # -
ZONING- ENG.SITE NO.
INSULATION PLUMBING
GAS
MECHANICAL
FIRE SPR INK ENERGY T 24
YE) N❑ v0 N�
COVER NO WORK UNTIL ABOVE HAS BEEN SIGN O j HEATING
FLOOD ZONE. A.L.U.C.
' LATH-INTERIOR - ELECTRICAL
LATH-EXTERIOR FIRE DEPT. Y ❑ NE] 11 Y 0 N❑'
SHEETROCK GRADE FEE SUMMARY I'
SHEAR INTERIORG -$Q�-
SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING
FIREWALLS' ELECTRIC PLAN CHECK
1 GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY I SEISMIC FEE I
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINALISSIGNED BY BUILDING INSPECTOR. MICROFILM
\ ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
H ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
- 1 Z PLEASE GIVE JOB ADDRESS WHEN PHONING.
— SEE PERMIT FOR EXPIRATION DATE — MECHANICAL
CONST.TAX
IMPORTANT!
PLEASE READ REVERSE SIDE BEFORE
CALLING FOR FINAL INSPECTION. TOTAL I /
.'OFFICECOPY I
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENT]FIC N PERMIT NUMBER
BUILDING APPLICATION & PIT 522
AooREs®� BUILDING - ELECTRICAL-PLUMB2
ING-MECHANICAL [I 6
OWNERS /7V PLAN CHECK VALIDATION
IIs' NAME a OTY, ELECTRIC PERMIT FEE
s
F A e1.r/ PHONE
CONTRACTORS,
I\ ,� NAME _ / UTLETS-SWITCHES-RECEP 10.00/1.00
/ A/ew A` 6�gsS 1�c.No. /O� LIGHTING FIXTURES 10.00/1.00
ADDREAcrogS PPLIANCES-RESIDENTIAL 4.00
CONTRACTORS
i;
SeI104 h PHOPANELS 10.00 PATE OF APPLICATION
ARCHITECT A NEL S (OVER 200 AMP) 20.00 PLAN CHECK P.C.NO.
OR
ENGINEER
uc.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00 �D
ADDREs NrS MOTORS SEE FEE SCH.
AOORLu
SERVICE CHANGE 20.00 O
APR n�p O 1geO7
'00
0o LICENSED CONTRACTORS DECLARATION
< u u I hereby affirm that 1 am licensed undo provisions of Chapter 9 E TE
A a w (commencing with Section 7000)of Division 3 of the Business and B MECH.
H °`a2 z Professions Code,and my license is in lull forc - ❑ ❑ ❑
0 o Liceco Number-
q ° Dat �)yav
nses lass es Contractor BUILDING PERMIT
¢ rc w OWNER-BUILDER DECLARATION INFORMATION
wH I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
uoa Law for the following mason. 7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
� - Code:Any city or county which rectums a permit to construct,alter,
ce rt ¢ p improve,demolish.or repair any structure,prior to its issuance,also ELEC.CONTR. - LIC.NO. ELEC.
O es requires the applicant for such pemit to file a signed statement that TOTAL PERMIT TO
E
he is licensed pursuant to the provisions of the Contractor's License I 16
H z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Basineu and Professions Code)or that ht,is exempt therefrom and QTY. PLUMBING PERMIT FEE
x ° BTO IE T C N
¢ r the basis for the alleged exemption.Any violation of Section 7031.5 1
a ; _ by any applicant for a permit subject,the applicant loa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not mom than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP .RES.UNITS
their Made 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
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 S0.FT.FLOOR AREA TOTAL ACREAGE
•
himselfornot
hded or employees,sarovided that owever.the
improve- GAS-EA.SYSTEM-l 6.00
mems are not intended or offered ee,pr If,however.such
building
or improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- qE5 IND Pa OdOo
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ r ❑ ❑'
licensed contractors to corutmm the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSO SP CEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts far such projects with a contract.,(,)licensed pursuant to
ilia Contractor's License Law. SEWER-SANITARY-STORM EA.200Pt/10.00 TRACT NO. PARCEL NO.
O l am exempt under Sec.-,B&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACO.FILE NO.
W'ORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofcommnt to self-insure, ZONING ENG.SITE NO.
or a certificate of Worke ,Lpmpenwtion Insurance,or a certified
Copy there.(( e' {. -)..
Policy N ompany
Q ❑ Certified copy ish rah umished. FIRE SPRINK ENERGY T-]/
Z ��. ❑ Ccrtifi n fit with h city ins anon'division. MISC- REFER TO ORD.
0/ (1\Pph"cam) Y❑ N❑ Y ❑ N❑
fL w �Pf!RTIFICA'I'E 1'F.XF. TION FROM WORK1iRS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.u.c.
W >_ COM E NS ATION INSURANCE PLO.CONTH. LIC.NO. PLG.
d (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
Z hundred dollars(51DO)or less.) '
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued,I shall not employ any parson in any manner so as to
O become subject td the Workers'Compensation Laws of California.
0. Data Applicant ALTER OR ADD TO MECH. 5.00 BUILDING 11 ISO
>_ N NOTIC17 TO APPLICANT: If,after making this Certil team of Ex.
F Z_ 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 shall be deemed cooked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONS IRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE t /
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. HEATING UNIT(TO 100,(100 B.T.U.) 8.00 MICROFILM
3097,Civ.0.).
Lender's Name
Lender's AddName HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 cattily that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4,00
information s correct:I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building comtruclion, and BOILER-CONP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city m enter upon the BOILER-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 on expense,which CONST.TAX
may in.any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
Bre f[h r MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
SigM21URIrOf PlICATIllucotractor Data s
OFFICE COPY