9201 rUJI InIJ u mnU INChin rnuimi Ur DUI LUIIVU
PFHMIt NUMRFR
CITY OF CUPERTINO 9201INSPECTION DIVISION
JOB INSPECTION RECORD
• PERMIT EXPIRATION JOB ADDRESS 6'/�Il Lt,.c/v'C���.. SIT# LOT#
'' I �f PERMIT EXPIRES IF WORK
OWNER U1. TRACTOR IS NOT STARTED WITHIN
INSPECTION. . ; DATE-, INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
ANCE OR 180 DAYS FROM
LIFER 11^�'r� .. •y -Q LAST CALLED INSPECTION.
PREGUNITEh„9,q-fv mK, urxA PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLABI— — tr lc
D
PLUMBING Id ?
ELECTRICAL – W _-V-- ('JET ISSUANCE DATE
MECHANICAL IT v -ZA PILr Fe LV�:• RL ELECT. PLG. NECK
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED Ley_ BUILDING PERMIT
7
WOOD FLOOR �� ,p <<. r�+ , C INFORMATION
VALUATIONS/FT.
PLUMBING
MECHANICAL
P MIT TO
ELECTRICAL
FRAMING
INSULATION sTO IES( TYPE CONSTR.
,.
UC .GROUP RES.UNRS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF SO FT FLOOR AREA TOTAL ACREAGE
• DIAPHRAGM
BUILDING USE
RES IND CON PR Omer
0 El
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED
ASSESSORS PARCEL NO.
ROUGH
PLUMBING
GAS TEST TRACT NO. PARCEL NO.
MECHANICAL
ELECTRICALFINALS DATE INSP. ACC DATE ACC,FILE NO
_y'-•&' �
FRAMING SAN n I
INSULATION PLUMBING I ZONING ENG.SITE NO.
GAS
FIRE SPRINK ENERGY iZA
MECHANICAL v N❑ Y E] N[:]
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
FL000 ZONE aL.uc.
LATH–INTERIOR ELECTRICAL - . -
LATH–EXTERIOR FIRE DEPT. Y❑ N[3 Y ❑ NE]
SHEETROCK GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING p ClQ e—u '2 BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS
FIREWALLS 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 IS SIGNED BY BUILDING INSPECTOR. MICROFILM -
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
o� ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
• Z PLEASE GIVE JOB ADDRESS WHEN PHONING.
- SEE PERMIT FOR EXPIRATION DATE - MECHANICAL
CONST.TAX
IMPORTANT!
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY '
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ON Y
' BUILDING PROJECT IDENTIFICATION PER MIT NUMBER
BUILDING APPLICATION & PERMIT 9201
ADDR s I
B ILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S TV ELECTRIC PERMIT FEE PLAN CHECK VALIDATION
AME`f I
�/ E
CONTRACTOR'S
NAME I I $ UTLETS-SWITCHES-RECEP 10.00/1.00 3�
Lm.NO. 50 LIGHTING FIXTURES 10.00/1.00 II V
ADDRESS TOR's PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHEC77 CHECKP.C.NO.
OR PANELS (OVER 200 AMP) 20.00
'K>/DVfE ISIGNS TRANS. 3.00
NCH.OR ENG. PERMIT VALIDATION
ADDRESS - SPECIAL CIRCUIT 5,00
E5 sU CAO-L.idS �Aiv`�tt`{ f2IP D- TEMP.METER OR POLE INS. 20.00
APPLIDACESS s
AOORESS - 0- MOTORS SEE FEE SCH.
Q - SERVICE CHANGE PAJU 20.00
w o a LICENSED CONTRACTORS DECLARATION O- TEMP.POLE 30.0 /•7 ��
< u U 1 hereby affirm that I am licensed under provisions of Chapter 9AUG I A A100
y (commencing with Section 7000)of Division 3 of the Business and
y a B G. T. PLG. MECH.
F 7 z Professions Code,and my license is in full force and effect.
Z,z T o License Class Lin.Number C� Qf �pe�
Dale Contractor L7
P: m s -�+ BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
M
d u INFORMATION
w g I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
U.Orst %VALUATIONS/FT.
jLaw for the following reason.(See.7031.5,Business and Professions PERMIT ISSUANCE 10.00 Code:Anycity orcounty which strutune permit o itsi sura alter,¢M¢Q improve,demolish,Dr repair any structure,prior to its issuance,also ELEC.CONTR. LIG.NO. ELEC. LNLLrequires the applicant for such permit t0 GIC a signed statement that TOTALQ ova w rn he is licensed pursuant to the provisions of the Contractor's LicensevaLaw(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe
oBusiness and Professions Code)or that he is exempt therefromandOTY. PLUMBING PERMIT FEE
¢ H .� the basis for the alleged exemption.Any violation of Section 703 LS C STaby any applicant for a permit subjects the applicant too civil penallyALTER-DRAIN&VER1T-WATER (EA.) 5.00of not more than five hundred dollars(5500).):❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE' 4.00their Sole compensation,will do the work,and lire structure is not ` VIRES.UNITS
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 F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE .
himself n through his own employees,provided that such improve- ea-7=
are not intended or employee', le lb ed that such
he building GAS-EA.SYSTEM•1 1NC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IE 2.00
builder will have the burden of proving that he did not build or im- BUILDI USE
P
rove for purpose of Sale.). RES IND N PB Other
INDUSTRIAL WASTE IN 30.00
Z ❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LfLAWN SPRINKLERS-1 INC V .00 ASSESSO 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 SPR INKLERS- ( A.
contracts for such projects with a contractogs)licensed pursuant to -
(be Contractor's License Law. SEWER-SAN ITARV-STORM EA.200ft 0 Q TRACT NO. PARCEL NO.
reas❑ lam exempt under Sec. ,d.&P.C.for this WATER HEATER W/V�tiyo 6.00
on
Owner Ste WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'C MPF:NSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-ino re' -
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.G).
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T24
Z Z ❑ Certified copy.is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Cer Y❑ N❑ Y ❑ N❑
Fps PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
UJ CERTIFICATEPE EXEMPTION FROM WORKERS' O
W � COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This Section need not be Completed if the permit is for one TOTAL pT Y❑ N❑ Y,F] IN
:D Z hundred dollars IS 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 I- mit is issued,I shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws of California: BUILDING
Is. Date-Applicant ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex..
F 2 Sorption,you should became subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of lire Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10 .M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1OPW.RIVIC00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WIT T 5.00
the performance of the work for which this permit is issued(See. MICROFILM
3097,CN.C.). HEATING UNIT(TO 100,000 B. .
Lender's Name HEATING UNIT IOVER 1 .U.)9,50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 py
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 JT
hereby authorize representatives of this city to enter upon the g01 LER-COMP lover 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 PERMIT ISSUANCE 10.00 CONST.TAX
may ins any way cerue against said City in conuquenc of the Q
gre gOf[hu r i q MECH.CONT. LIC.NO. MECH.
�/�/ r1 TOTAL �7[rd TOTAL `'A S-4,
Sign ure o'f pplicant/Contmctor -U /- 7 "\
OFFICE COPY