13640 POST THIS CARD NEAR FRONT OF BUILDING .
CITY OF CUPERTINO PF
R+M�ITQN�(�';BER
INSPECTION DIVISION i {�{1�Q
JOB INSPECTION RECORD
. JOB ADDRESS 10900 BLANEY PERMIT EXPIRATION
UNIT# � _Lor#
PG&E PERMIT EXPIRES IF WORK
OWNER CONTRACTOR B.T: ELECTRIC IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU.
FOUNDATION -CF' ANCE OR 180 DAYS FROM
UFER LASTCALLED INSPECTION:
FELECTRICAL
ITE PERMIT VALIDATION
O CONCRETE UNTIL ABOVE HAS BEEN SIGNED -
UNDERGROUND /SLAB
NG
ISSu NCE DATEICAL - eLDc. E T. PLc. MEDIA.
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED �� r BUI DING PERMIT
WOOD FLOOR yup, �hG INFORMATION
PLUMBING - VALUATION $/FT.
MECHANICAL
ELECTRICAL P/ERM�ITTOT
FRAMING
INSULATION - $TORIES TYPE CONSTR,
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF SO.FT,FL 00 AREA TOTAL ACREAGE
DIAPHRAGM
- RUIL CON uSE
" RES IND CON PB O,he,
VELECTRICAL
O ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑ ❑ ❑
ROUGH ASSESSORS PARCEL NO.
TRACT NO. PARCEL No.
AL,
M
INSP. ACC.DATE ACG FILE NO.
SAN ON , PLUZONING ENG.SITE NO.
GAS
MEC - FIRE SPRINK __ENERGYT24
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEAY ❑ N❑ Y ❑ N❑
LATH—INTERIOR- ELEC .FLOOD ZONE A.L c.
LATH—EXTERIOR FIRE DEPT. Y❑ N❑ Y ❑ No
SHEETROCK - GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING
SHEAR ExTERIORTEMPORARY APPROVALS BUILDING
FIREWALLS - ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED JOCCUPANCY SEISMIC FEE
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 0� 252-4505, ELECTRIC ONE WORKING DAY BEFORE REQUIRED, INSPECTION. PLUNBwc
Z. 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
APPLICATION & PERMIT
- +
BUILDING
Aoo F (f O BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 13640
o /3 w w
OwrvER'a - PLAN CHECK VALIDATION
NAME
A DTV. ELECTRIC PERMIT FEE
PHONE
CONTRACTOR
NAME
NaME OUTLETS-SWITCHES-RECEP 10.00/1,00
9. f y, �=�-'ea�r is& LIC,NO, 3.3173 2' LIGHTING FIXTURES 10.00/1.00
CONTRACTOR
's
ADDRESS
APPLIANCES-RESIDENTIAL 4.00
� O( PANELS IO.00
DATE OF APPLICATION2- oJ
ORCHITECT VPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0,
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 S.DO PERMIT VALIDATION
ADDREZIP rTEMP.METER OR POLE INS. 20,00 \
ADDRESS MOTORS SEE FEE SCH. �Q n
5 -w,.(� SERVICE CHAN 20.00
00o W
LICENSED CONTRACTORS DECLARATION 7
zI hereby affirm that I am licensed under provisions of Chapter 9 r ISSUANCE DATE
w Q e. (commencing with Section 7000)of Division 3 of the Business and r BLDG. ELECT. PLG. MECH.
H o z Professions Code and my license is in full force and effect. Cs O ❑
Z O - Licensa�-Class (U Lic.Number L f
Q m H Date-T'2•�Contractor C
a x E � G\� BUILDING PERMIT
CC w ar OWNER-BUILDER DECLARATION INFORMATION '
w ;LL P I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
P n 0 4 Law for the following reason.(See,703 1.5,Businessand Professions PERMIT ISSUANCE 10.00 (0,60 VALUATION $/FT.
w 0 Code:Any city or county which requires a permit to construct,alter,
2 2 Q O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.N0. ELEC.'
O LL requires the applicant for such permit to file a signed statement that ,7 ALL..6P 2.
3�H7 3 3' TOTAL PERMIT TO
a. w w he is licensed pursuant to the provisions of the Contractor's License T
r i >
Law(Chapter 9(commencingwilh Section 7000)of Division 3 ofthe __,
i o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
I-o the basis for the alleged exemption.Any violation of Section 703 LS I STORIES TYPE CONSTR.
a by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5,00
of not more than five hundred dollars($500)J:
❑ I,as owner of the property,or my employees with wages as. BACK F LOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.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 FIXTURES-PER TRAP 5.00 50.FT.FLOOR ATEA TOTAL ACREAGE
himself re through his own employees,provided that such improve-building
mems are not intended or offered for sale.If,however,the braiding GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is Sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omar
❑ I,as owner of the property,am exclusively contracting with 1:1 El 11 El ❑
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 contractor(s)licensed pursuant to SEWER-SAN EA.200ft/10,00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ l am exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACO.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to Sehhinsure,
or a certificate of Workers Compensation Insurance,or a certified _ ZONING ENG.SITE NO.
copy thereof(See.3800,Lab.CJ
Policy No. Company �a�:}xoaw:r. Ctt uAA
0 ❑ Certified copy is hereby furnished. - FIRE SPRINK ENERGY T-24
Z Z F Certifiedy is filed ith he city inspection division.
p: O Applicant e14 MISC.- REFER TO ORD. Y[:] N❑ Y ❑ N�
CC Ln CE TIFICATE O EXEMPTION FROM WO KERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANC PLG.CONTE. LIC.NO. PLO, [:]
-1
❑ N❑
C O (This section need not be completed if[he ermit is for one TOTAL Y N Y
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 H mil 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.
Date Applicant BUILDING
a ALTER OR ADD TO MECH. 5.00
} rel NOTICE TO APPLICANT: If,after making this Certificate Ex-
? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions the Labor Code, you mus[ forthwith comply with FEE
C.)
suchprovisions
ns or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000QF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.FM.) 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,). il'i 6 j� ,{� HEATING UNIT(TO 100,000 B.T.U.) -8.00 -
Lender'sAddr Cv HEATING UNIT(OV ER 100,000 B.T.U.)9.50ELECTRIC /S Ob
me
Lender's Address
I certify that I have read this 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 comilruelion, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 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 CONST.TAX
may 4anay accrue against said•City in consequence of thePERMIT ISSUANCE 10.00grantipermit MECH.CONT. LIC.NO. MECH.
7TOTAL TOTAL
Si appli n Contractor Dale O
OFFICE COPY '