11093 POST THIS CARD NEAR FRONT OF BUILDING
TERNIIr NUMBER
CITY OF CUPERTINO 11093
INSPECTION DIVISION
JOBINSPEC ION RECORD r
PERMIT EXPIRATION i
JOB ADDRESS ' UNIT# LOT# (.
PERMIT EXPIRES IF WORK
OWNER CONTRACTOR' IS NOT STARTED WITHIN
I SPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION ANCE OR 180 DAYS FROM
UFER LASTCALLED INSPECTION.
PREGUNITE PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED ,
UNDERGROUND /SLAB
PLUMBING
ELECTRICAL ISSUANCE DATE
MECHANICAL. - O�EDqyGG. ELECT. PLG. MECH.
LR` ® 1 ❑
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR VALUATION S/FT.
PLUMBING - '1
MECHANICAL
ELECTRICAL PERM I TO
FRAMING
INSULATION STORIES T ECONSTR.
•
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
SO.FT.FLOOR AREA TOTAL ACREAGE
4 ROOF
DIAPHRAGM
BUILDING USE
RES Irvo coN PO olnr,
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED 0 cl .El 0 1:1
ASSESSORS PARCEL NO.
ROUGH
PLUMBING
GAS TEST --TRACT No. PARCEL No.
MECHANICAL
ACC,DATE ACC.FILE NO.
ELECTRICAL py FINALS DATE INSP.
FRAMING SAN #
' ZONING ENG.SITE NO.
INSULATION PLUM IN I
GAS
FIRE SPRINK ENERGY T 24
' MEC ANICAL v � N� v Q ' N�
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEA INC
FL ODZONE A_L.UC.
LATH-INTERIOR EI TRICAL YC) N Y0 N❑
LATH—EXTERIOR FIRE
SHEETROCK GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING
SHEAR EXTERIOR . TEMPORARY APPROVALS BUILDING
FIREWALLS ELECTRIC PLAN CHECK
F /
- GAS EE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCY OF BUILDING ISNOTPERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY P=INSPECTII
ELECTRIC
•w ONE WORKING DAY BEFORE REQPLUMBING
Z� PLEASE GIVE JOB ADDRESS WHE- SEE PERMIT FOR'EXPIRAMECHANICAL
IMPORTANT! '
CONST.TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL ` �-
CALLING FOR FINAL INSPECTION.
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
9UI LDING PROJECT IDENTIFICATION PERMIT NUMBER
IaILOINt APPLICATION & PERMIT 11093
AOO Ess
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'sJ ff PLAN CHECK VALIONZION
OTV. ELECTRIC PERMIT FEE �0 `'1. r�-/p\•
CONTRAC OR'a B•
3
NA LIUTLETS-SWITCHES-RECEP 10.00/1.00
GHTING FIXTURES 10.00/1.00
at
CONT CTOR's
ADDRESS -_ PPLIANCES-RESIDENTIAL 4.00
it
PHONE PANELS 10.00 PATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
A
RCHE OR ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20,00
APPLICANTS MOTORS SEE FEE SCH.
AD REI; Es ��,��/ (�r ✓
Ire
✓� ya,.�l•-/".'
SERVICE CHANGE 20.00 /
w o z LICENSED CONTRACTORS DECLARATION 4 ,?10,✓
a u S~a I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N c y (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H N rosefessiors Code,and my license is in full force and effect. ❑
oi w o LicenClass Lic.Number
F m H J Datc Contractor
¢ , s -1 BUILDING PERMIT
¢ ¢w ¢ OWNER-BUILDER DF.CLARA'rlON INFORMATION
O d 0 MISC.- REFER TO ORD
X g LL N 1 hereby affirm that I am exempt from the Contractor's License' VALUATION S/FT.
u O¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
ry0 LI Code:Any city or county which requires a permit to construct,alter,
2 to Q p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
LL regnlre9 the applicant for SOCK permit IO IIIC a sIgOL`J Stalenlem that TOTAL .PERMIT TO
n w mhe is licensed pursuant to the provisions of the Contractor's License {. (1
Hzi
Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe /N rear-,d //7/OQe
z o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ I-Q the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permitsubjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(4500).):
❑ 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 offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Cade:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- -
Huntsarenotintendedoroffered for Sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden Of proving that lie did'not build or int- BUILDING USE
PTfor purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
I,as owner of the property,am exclusively contract g with Cl ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044 usiness LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contrac tar's L''ense do not apply
to an owner of p perry who builds or pr s it,
on.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
Contracts for su projects wi(ha con c(o It dpursuant to SEWER-SANITARY-STORM EA.200ft/10.00
tat Contracto License aw. TRACT NO. PARCEL NO.
❑ lam mpt under ,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date' - WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAIION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a Certificate of Consent in salf-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified Copy is hereby furnished. FIRESPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ N❑
W CER'IT FICAI'E Oh EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10,00 FLOOD ZONE A.L.U.O.
LU >_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section need not he completed if the permit is for one TOTAL V❑ N❑ Y ❑ N❑
D Z hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California. 7
i
Date.Applicant Applicant p ALTER OR ADD TO MECH. 5.00 BUILDING 6R
} m NOTICE TO APPLICANT: If,after making this Certificate Of E.--
Emptier,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of rhe Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000C.F.M.) 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 HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC Q
Lender's Address
T/• I certify that l have read(his application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and countyPLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.Or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL
above-mentio d property for inspec(ton pu oses.
(We) ag a to save, indemnify and ep h le he City of MISC.- REFER TO ORD.
Cupertin gainst liabilities,judgme co nd parses which pEfl MIT ISSUANCE 10.00 CONST.TAX
may i y way to
again C' in sequence of the
gran of this perm MECH.CONT. LIC.NO. MECH. p
-2.7-
TOTAL TOTAL Q 1�
gna(ure of Applican on[racl Dale
OFFICE COPY