12281 POST THIS CARD NEAR FRONT OF BUILDING
PERMIT NUMBER
CITY OF CUPERTINO
INSPECTION DIV'ISION '. 12281.
JOB INSPECTION.RECORD
PERMIT EXPIRATION
JOB ADDRESS myJ ✓ �� uy UNIT OT#
PERMIT EXPIRES IF WORK '
OWNER - CONTRACTORS IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR If I SPEC RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION ANCE OR 180 DAYS FROM
LIFER
LASTCALLED INSPECTION.
� .
PREGUNITE - _ PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS-BEEN SIGNED -�
UNDERGROUND /SLAB
PLUMBING g'In .
ELECTRICAL ISSUANCE DA E
MECHANICAL BLDG. ELECT. PLG. MECH.
0 0 0
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
WOOD FLOOR INFORMATION
•' VALUATION
SIFT.•
PLUMBING
MECHANICAL
ELECTRICAL PERMIT To
FRAMING
INSULATION _ STORIES TYPE CONSTR.
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED -
ROOF SO.FT,FLOOR AHEIITOTAL ACREAGE
DIAPHRAGM*
BUILDING USE
RES IND CON PB OW.,
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ 0 0 0 E:l
ASSESSORS PARCEL NO.
ROUGH
PLUMBING
GAS TEST - -TRACT NO. PARCEL NO.
MECHANICAL
ACC.DATE , ACC.FILE NO.
ELECTRICAL FINALS' '4DATE INSP.
FRAMING SAN *
ZONING ENG.SITE NO:
INSULATION PLUMBING
GAS
` MECHANICAL FIRE SPRINH ENERGY T.2a
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING �. "❑ v'� NE]
C
U
L. . .
LATH-INTERIOR ELECTRICAL FLOOD ZONE A. '
LATH-EXTERIOR FIRE DEPT. Yo No Yo NO
SHEETROCKJ $`, GRADE- FEE SUMMARY
SHEAR INTERIOR "LI BUILDING -
SHEAR EXTERIOR TEMPORARY APPROVALS 'BUILDING
�T
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
F_ 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 ONLY
- ' BUILDINGPROJECT I DENTIFICATI ON - PERMIT NUMBER
BOILDING APPLICATION & PERMIT
ADORES$3SS (np BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 12281
OwrvER66'sPLAN CHECK VALIDATION
QTY. ELECTRICIPERMIT FEE
♦ &f•>CI�IQ'f' PHONE
CONTRACTOR'SOUTLETS-SWITCHES-RECEP 10.00/1.00'
NAME _
FP
RMI it LIC.NO. LIGHTING FIXTURES 10.00/1.00 1 -
rONTRACTOR's - APPLIANCES-RESIDENTIAL 4.00
ADDRESS (IVIS)
PHONE SUE( PANELS r 10.00 - DATE OF APPLICATION
A CHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
US.No. SIGNS TRANS. 3.00
ARCH,OR ENG. •. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
zw TEMP.METER OR POLE INS. 20.00 I
APPLICANTS - MOTORS SEE FEE SCH.
ADDRESS N
SERVICE CHANGE - 20.00 �F�14
F o o LICENSED CONTRACTORS DECLARATION
<v U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and , MECH.
r ,w BLOG. ELECT. PLG.Professions Code,and my license is in full force ❑ ❑ ❑ ❑
z o,Tri, - Licanse Class Lic.Number YY TT V
O a, r Date /"i" Contractor
a r E� _ i It" BUILDING PERMIT,
¢ 2 w G OWNER-BUIL DERDECLAR TION• • INFORMATION'
wo a ° REFER TO ORD
3 a N I hereby affirm that I am exempt from the Contractor's License M ISC.-
FaOj Law far the following reason. 7031.5,Ifmu,cssand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
m Code:Any city or county which requiresapermit to construct,alter,IS ' -
¢ G 2 improve,demolish,or repair any structure,"prior to its issuance,also ELEC.CONTR. - LIC.N0.- 2
as
O LL requires the applicant such ELEC.
q pp permit to file a signed statement that TOTAL PER
w $ he is licensed pursuant to the provisions of the Contractor's License - '
Fzi Law(Chapter9(commencing with Section 7000)of Division 3 of the "I
a: Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE-
rc r o the basis far the alleged exemption.Any violation of Section 7031.5 STORIES TYPt CONSTR.
'a by any applicant for a permit subjects the applicant to a civil penalty gLTER-DRAIN -WATER IEA) 5.00
or not more than five hundred dollars(5500).): . -
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS sole compensation,will do the work,and the structure n 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
himself or through his own employees,provided that such improve-
mentsarenutintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4(EA) 200 BUILDING USE
builder will have the burden of proving that h . . .
e did not hand or im- RES IND CON PB Orner
Prove for purpose of,ale.f. INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
❑ 1,as owner of the property,am exclusively contracting with
licensed 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 contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ftI10.00 TRACT NO, PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner -Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,-or a certified
copy thereof(See.3800,Lab.CJ �(l�y�
Policy No. Company a
❑ Certified copy is hereby fu to led. FIRE SPRINK ENERGY T-24
Z O Getlifie} cap i�fJrA with the,rlty inspection division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
A pllcant /�- v N V N
Fy PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.Uc.
CERTIFI TE OF EXEMPTION FROM WORKERS'
ill"- COMPENSATION INSURANCE PLG.CONTR. LIC,NO, PLG.'
1 O (This station•naed not be completed if the permit is for one - TOTAL Y[:]- N❑ Y CDN❑
Z hundred dollars(S100)or IesSJ - s -
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to I '
U become subject to•the Workers'Compensation Laws of California. -0 7
W Datc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING 0`�5
} to NOTICE TO APPLICANT'.If,after making this Certificate of Ex-
F- ? emption,you should become subject to the workers'Compensation APPLIANCE - 5.00 PLAN CHECK
provisions of the,Labor Code, you must.forthwilh comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
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 for EXHAUST HOOD(WITH DUCT) 5.00
the performance'of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 - MICROFILM
3097,CN.CJ. -
Leader's Name H EATI NG U N IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
. I certify that I have dead this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. Lagree to comply with all city and county PLUMBING
'ordinances and state laws relating to building construction, andBOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP poser 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned properly Introspection purposes.
(We) agree to save, indemnify and keep.harndess the City of MISC.- REFER TO ORD.
Cupertino against liabilities judgments, costa and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue mind said Ci/'tyyi'��-'•(.';'¢upence of the '
Oft is per MECH.CONT. LIC.N0. MECH.
TOTAL TOTAL It
ignature of I'lie
ontractor Date ' -
• •- OFFICE COPY '