16567 I. POST THIS CARD NEAR FRONT OF1 BUILDING .
PERMITNUMSEH *
CITY OF • LIPERTINO
DIVISION 16567
INSPECTION
JOB.INSPECTION,RECORD i
PERMIT EXPIRATION
JOB ADDRESS/- Lrel UNIT# LO!UL �- -
WaI 1 T# PERMIT EXPIRES IF WORK
OWNER CONTRACTOR IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU�_
FOUNDATION - ANCE OR 180 DAYS FROM
NOTE:•, LASTCALLED INSPECTION.
LIFER. ALL GRADING AND DRAINAGE SHALL BE INSTALLED
TO COMPLY WITH THE APPROVED PLANS AND CITY OF - `PERMIT VALIDATION
PREGUNITE . CUPERTINO STANDARD S.
GARAGESLABS - -
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
.UNDERGROUND /.SLAB , i . 1• t
PLUMBING '
ELECTRICAL ' • T ISSUANCE DATE
MECHANICAL:' - F7 ELECT. PLG, MECR
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD.FLOOR
- - 1 vALunnoNSIFT
PLUMBING .
MECHANICAL'.' - i '• -
ELECTRICAL PERMIT TO
FRAMING. .. �.
` STORIES TYPE CONSTR.
INSULATION' �•.' +. . _ ,
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED - -
ROOF NOTE:NO FINAL NSP.'SHALC BE MADE BEFORE SO FT.FLOOR ARIA TOTAILACREAGE
DIAPHRAGM THE CONSTRUCTION TAX IS PAID
BUILOIrvG USE
ROOF SHEATHING . ' RES IND CON' PR oln.,
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP. . El ❑ .❑ ❑
ASSESSORS PARCEL NO
ROUGH SAN.M
PLUMBING ELECT,ENERGY `
TRACT,NU,' PARCEL NO
TUBS 8 SHOWER PAN PLUMBING ENERGY _ •
MECHANICAL' - MECH.ENERGY-
ELECTRICAL .,
. ACC DATE ACC.FILE NO
BUILDING ENERGY -
FRAMING - ' ELECT,FINAL TEST
INSULATION' PLUMBING
_ ZONING ENG.SITE NO,
� � � � �� - '
'GAS TEST GAS -
MECHANICAL - FIRE SPRINK ENERGY F4A
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING . ❑ "❑ ° ❑ N❑,
EXTERIOR SHEARELECTRICAL RELEASE FLOODZONE A.L UC. 1
INTERIOR SHEAR FIRE DEPT.- '° ❑ ;,N❑ ° ❑ N❑',
SHEETROCK' - GRADE F ESUMMARY
EXTERIOR LATH" BUILDING - - -
INTERIOR LATH TEMPORARY APPROVALS BUILDING 1
SCRATCH COAT ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED JOCCUPANCY - SEISMIC FEE
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR. MICROFILM'
ARRANGE FOR INSPECTION BY PHONING 252-4505, ' , ELECTRIC ' .
�' ONE WORKING DAY-BEFORE REQUI:RED'INSPECTION.•. ,
• - PLUMBING: -
z�..', PLEASE GFVE'JOB ADDRESS WHEN PHONING.
x{{. MECHANICAL
— SEE PERMIT FOR EXPIRATION DATE - U
IMPORTANT! ¢ CONST.TAX '
l' t • -PLEASE READ REVERSE SIDE BEFORE � '� TOTAL
CALLING FOR,FINAL INSPECTION.
OFFICE COPY I
APPLICANT'TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY '
BUILDING PROJECT IDENTIFICATION- - -PERMITNUMBER _
pooREs: /01 �3 /f, oI C 020 APPLICATION & PERMIT ' nn f/J
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL' ' 1'6567
NAM - -
E 's PLAN CHECK VALIDATION
NAME ELECTRIC PERMIT FEE -
If 5 PRO EDt/� STJ-D
CONTRACTOR'S '
NAME �• UTLETS-SWITCHES'-RECEP 10.00/1.00,
J 4 MC44 Na, a( 33-2Z LIGHTING FIXTURES, 10.00/1.00
CONTRACTOR'S
AOOHEss �J1tl - ' / APPLIANCES-,RESIDENTIAL ;'4.00
fes! S )ONE a9�-,,�7�!6b _ PANELS - .10.00 DATE OF APPLICATION•T' '
CR TECT PLAN CHECK FEE P,C.,NO.
OR - PANELS (OVER 200 AMP). 20.00 - „
ENGINEER
LIC.40. - SIGNS TRANS. v 3.00 .
AROR,OR ENG. , PERMIT VALIDATION
aODREss - I SPECIALCIRCUIT ^ 5.00 • ,
zap TEMP.METER OR POLE INS. 20.00
• APPLICANT'S
ADDRESS MOTORS SEPFEE SCH.
SERVICE CHANGE 20.00
O o. LICENSED CONTRACTORS DECLARATION
au U I hereby affirm that I am licensed under provisions of Chapter 9
Z w ISSUANCE DATE
G Q w (commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLG. -MECH.
H O i Professions Cod nd n I' ense is in full force a 8 effect ❑ ❑ ❑
z O License Class �}7,.�yy Lie.Number .2 1'
9 -ae Data I�IL_a+_�gConlractor El 5FFEET ,
F N R J
Q
J
>e - BUILDING PERMIT
¢ ¢w Q OWNER-BUILDER DECLARATION
°' U - MISC. , REFER TO ORD 'INFORMATION
'x a. r 1 hereby affirm that Taco a%cent Gom'B Business Contractor's License "VALUATION $/FT.
u as j Law for Ilse following reason.(Sec.requires a,ermt toc and Professions
� -w PERMIT ISSUANCE 10.00 '
4m� Code:Anymolish cor ntywhiny Struturep prior
construct,
¢ ¢Q FO improve,demolish,or repair any structure,prior to its issuance,also ELEC. LID.NO. ; ELEC.
° LL requires the applicant for such revisit to file ir signed statement i Del TOTAL
PERMIT TO
X
$ he is licensed pursuant to the provisions of the Contractor's License
R x 4 taw(Chapter 9(I»Professions
Cod with Section is exempt
of Division 3 of the -
3 4 o Business and Professions Code)or that he is cion of ection 70 and QTY. PLUMBING PERMIT FEE
¢ H � y by anybas
the allegedexemption.uonduithe violation of Section malty STORIES TYPE CONSTR.
by any applicant fora permit subjects the applicant toa civil renally
of not more than five hundred dollars(5500).): ALTER-DRAIN& VENT-WATER (EA.) 5.00 '
❑ 1,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 nal
intended or offered for sale(Sec. 7044, Business and Professimss DRAINS-FLOOR,ROOF;AREA;COND.. 5.00
Code:'the Contractors License Law does not apply to an owner of _
. property who builds or insprovesthereon,and who does such work FIXTURES=PERTRAP' 5.00 ' SO:FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotinlendedorufferedforsale.If,however,the building GAS-EA.SYSTEM-111NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner,
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
'
trove for purpose ofsthe
RES IND
- �.. 'CO
❑ 1,as owner of[he property,am exclusively contracting with CON PB Other
INDUSTRIAL WASTE INTER. 30.00
El 11
licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS-1'INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law does not apply I;
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such ponive s with a com,actraps)licensed pursuant m SEWER-SANITARY-STORM EA'.200ft/10.00
the Contractors License Law. TRACT NO, PARCEL NO.
❑ lam exempt under Sec. .,BAP.C.for this
reason WATER HEATER W/VENT 6.00
Owner' - Date WATER SYSTEM5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMITNSATION DECLARATION ' WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to self-insure.
' 4 a certificate of Workers'Compensation Insurance,or a certified - ZONING ENG.SITE NO.
copy thereof ISe 3890,Lab C.)p. / "
Policy No. ompany d '1 /IIH 0 h
�❑/_Cetllie is herchy famished, - ,FIRESPAINK - ENERGY T-14
Z Z' y+Cerlificd o is file) with th icily inspection Jivisims. e
O APPlicantilIN _ j.q ka---- =,)P.
MISC.- REFER TO ORD., y ,y YF] N[]
CC y CERTIFICATE OI'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU - COMPENSATION INSURANCE PLG.CONT9, LIC.NO.
CL Z (This section need not he completed if the permit is for one AL - Y[) NE] Y 0 NEI
hundred dollars IS 100)m less.) CS
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT, `1 FEE SUMMARY
LL )- 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. A _ -
y :. Date ApplicnntBUILDING
>_ m NOTICE TO APPLICANT: If,after making this Certificate of fix. ALTER OR ADD TO MECH. 1Q8 07
F ? emption,you should become subject to the Workers'Compensation APPLIANCE 1�. 0 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. I AIR HANDLING UNIT(TO 1Q000C.F.M.) 4.00 6
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 ,. SEISMIC FEE
I hereby affirm that there is a construction lending agency I'or EXHAUST HOOD (WITH.DUCT) 5.00 -
the performance of the work for which this permit is issued(See MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 6.00 -
Lender's Name HEATING UNIT(O V ER 100,000 B.T.U.)Lender's Address . ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4,00
.� information is correct, 1 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
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOI LER-COMP Dome 100,000 BTU)SEE FEE SCH. IVI ECHANICAL
(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 1480. /?.UO CONST.TAX r
may in any way accrue against said.City in consequence of the
ranting of this permit, - MECH.CONT. LIC.NO: MECH. .
. TOTAL TOTAL
Signature of Applicant/Cswarractar Da -
OFFICE COPY