13114 7
�c POST THIS CARD NEAR FRONT OF BUILDING
PERMIT NUMBER
CITY OF CUPERTINO 13114
INSPECTION DIVISION
JOB INSPECTION RECORD
•�, PERMIT EXPIRATION
JOB ADDRESS 10564 No. 'Blaney UNIT# LOT#
PERMIT EXPIRES IF WORK'
OWNER Ann Cunv CONTRACTOR J&M Termite IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION ANCE OR 180 DAYS FROM
LIFER
LAST CALLED INSPECTION.
PREGUNITE PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB
PLUMBING ,4
L
ELECTRICAL - Iss NCE AYE
MECHANICAL ` e G. I ELEtT. If PLG. I MECH.
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
PLUMBING
WOOD FLOOR - VALUATION $/FT.
- _ -
MECHANICAL - ,;,-
ELECTRICAL - - PERM n-r,QI
FRAMING
INSULATION - SlyJRIES TYPE CONSTR.
OCC.GROUP RES,UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
. ROOF SO,FT,FLOOR AREA TOTAL ACREAGE
DIAPHRAGM
- BUILDING USE
RES IND. CON PB Other
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑ ❑ ❑ '
-ASSESSORS PARCEL N0.
ROUGH
PLUMBING
GAS TEST TRACT NO. PARCEL NO.
MECHANICAL ACC.DATE - ACC.FILE NO,
.. ELECTRICAL FINALS DATE INSP. '
FRAMING SAN #
ZONING ENG.SITE NO.
- INSULATION PLUMBING -
GAS
MECHANICAL FIRE SPRINK ENERGY T 24
COVER NO WORK UNTIL ABOV S BEE SIGNED HEATING Y ❑ No Y ❑ N❑
FLOOD ZONE A,LU.C.
LATH—INTERIOR ELECTRICAL -
LATH—EXTERIOR FIRE DEPT. Y❑ No .Y❑ N❑
SHEETROCK GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING'
SHEAR EXTERIOR TEMPORARY APPROVALS - I 'BUILDING t
FIREWALLS ELECTRIC - PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCY OF BUILDING ISNOTPERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
I
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
LU
ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
'PLEASE GIVE JOB ADDRESS WHEN PHONING.
— SEE PERMIT FOR EXPIRATION DATE — MECHANICAL
• IMPORTANT! CONST.TAX
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
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT
ADDRESS o I 131,114
.
ADDRESS
o_ ILDING - ELECTRICAL-PLUMBING-MECHANICAL
NAME 'S - PLAN CHECK VALIDATION
NAME � QTY. ELECTRIC PERMIT FEE
1 f PHONE
rC.! ACTORS UTLEL-SWITCHES-RECEP 10.00/1.00
IC No.J p LIGHTING FIXTURES 10.00/1.00 '
CONTRACTORS
ADOREss PPLIANCES-RESIDENTIAL .4.00
d, LJ 6 $� PANELS 10.00 DATE OF APPLICATION
OARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.O.NO.
ENGINEER
uc.ND. SIGNS TRANS. 3.00
ARCH.OR ADDRESS ENO , SPECIALCIRCUIT 5.00 PER MIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20,00 �,✓ Q
APPLICANT'S U�
ADDRESS MOTORS SEE FEE SCH. t� U
SERVICE CHANGE 20.00 k7
woo LICENSED CONTRACTORS DECLARATION
¢v I,hereby affirm that I am licensed under provisions of Chapter 9 - t C�e� ( 7
w Z w 1 ISSUANCE DATE
¢e. (commencing with Section 7000)of Division 3 of the Business and - DG. ELECT. PLG. MECH.
H m z Professions Code,a my license is in full frceydeffpcL ❑ ❑ ❑
z0 i w G License la sec.Number J ST/ 1
H Date Contractor --�/ypr
M y
¢ R w a OWNER-BUILDER DECLARATION BUILDING PERMIT
o D INFORMATION
w 3:A N 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
L.w 00¢ Law for the following reason.(Sec.7031.5,Businessand Professions VALUATION $/FT.
r -wct, PERMIT ISSUANCE 10.00 �3 /L
Se improve,
Anymolish counpair any structure,
prior
t to
Se¢O improve,demolish,or repair any stmcture,prior to its issuance,also ELEC.CONTR. , LIC.NO. ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL PER
O
E
m he is licensed pursuant to the provisions of the Contractor's License nn
Law(Chapter 9(commencing with Section 7000)o f Division 3 of the
e 4 O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
« 1-$ the basis for the alleged exemption.Any violation of Section 7031.5 I STORIES TYPE CONSTR.
n 3.- by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will 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
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 TRAP5.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for Sale.If-,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 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
prove for purpose of sale.). - RES IND CON Pa Other
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
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 contmctons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO,
❑ I am exempt under Sec. ,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.GATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of ec usem to self-insure, -
or a certificate of Workers'Compens�a/tio Insurance,or a certified ZONING ENG.SITE NO.
COPY t cc /Z7
Policy N / C v
O ❑ Certified ereb a . FIRE SPRINK ENERGY T24
Z Z ❑ Certl py is 11 wi City chop division.
H O Applicant _ ( N - MISC.- REFER TO ORD. Y [] IN YE] N[3
�7 CERTIFICATE OF EXEMPTION FROM WORKERS" - PERMIT ISSUANCE 10.00FLOOD ZONE A.L.U.C.
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7 (This section need no[J be completed ION INSURANCE
tl eEpermit is for one PLG.CONTR. LIC.NO. LG TOTAL V N Y N�
ao
Z hundred dollars($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 F mit is issued,1 shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
d Date Applicant BUILDING
)- US NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 p
)... 2 emptlon,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V 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 EXHAUSBHOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). t HEATING UNIT(TO 100,000 B.T.U.) 6.00
Lender's Name
Lender's Address HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify Ihat 1 have read [,I,application and state that the above VENTILATION FAN (SINGLE) 4.00
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
hereby authorize this representatives othis city to enter upon the
above-mentioned property for representatives
inspection purposes. 00000 BOILER-COMP IOver 1BTU)SEE FEE SCH. MECHANICAL,
(We) agree to saveindemnify a d keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgn ts, costs and expenses which' ' PERMIT ISSUANCE 10.00 CONST.TAX
may in any accrue against id City in consequence of the
grantin isp MECH.CONT. UC.NO. MECH.
TOTAL TOTAL Ob
r rc of Applicant/Contractor Date -
OFFICE COPY -