12541 POST THIS CARD NEAR FRONT OF BUILDING
PERMIT NUMBER
CITY OF CUPERTINO 12541
INSPECTION DIVISION
JOB INSPECTION RECORD
PERMIT EXPIRATION
JOB ADDR ESS NIT# _LOT# PERMIT EXPIRES IF WORK
OWNER J CONTRACTOR IS NOT STARTED WITHIN
INSPECTI DATE INSPECTOR 1INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION - ANCE OR 180 DAYS FROM
LIFER
LAST CALLED INSPECTION.
PREGUNITE -
PERMIT VALIDATION
i r-✓
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB
PLUMBING
ELECTRICAL
ISSUANCE DATE
MECHANICAL BLDG. ELECT I PLG. -MECH.
❑ ❑ ❑
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
WOOD FLOOR INFORMATION
PLUMBING VALUATION $/FT.
MECHANICAL - -
ELECTRICAL PERj`^/n/(Ar,p9 �
FRAMING E
INSULATION STORIE9 TYPE CONSTR.
UCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF SO FT,FLOOR AREA TOTAL ACREAGE
Of
BUILDING USE
RES IND CON PB OInPI
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑ ❑ ❑
ROUGH ASSESSORS PARCEL NO.
PLUMBING
GAS TEST - - TRACT NO. PARCEL NO.
MECHANICAL
ELECTRICAL FINALS DATE INSP. ACC.DATE ACC.FILE NO.
FRAMING SAN it
INSULATION ,PLUMBING ZONING ENG.SITE NO.
GAS
MECHANICAL FIRE SPR N. ENERGY naa
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNEDHEATING `' ❑ N❑ I❑ No
LATH—INTERIOR ELECTRICAL FLDOD ZONE A.L.U.C.
LATH—EXTERIOR FIRE DEPT. Y ❑ N❑ v ❑ N❑
SHEETROCK GRADE
FEESUMMARY
SHEAR INTERIOR BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING
FIREWALLS ELECTRIC PLAN CHECK �-
GAS
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE —_
OCCUPANCY OF BUILDING IS NOTPERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
W, ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
$ ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
o�
z PLEASE GIVE JOB ADDRESS WHEN PHONING.
- SEE PERMIT FOR EXPIRATION DATE - MECHANICAL
IMPORTANT!
CONST.rax'
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
ILOING APPLICATION & PERMIT
E„1s bq Y1 �� -r �". BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 12541
OWNElRR S
PLAN CHECK VALIDATION
`A E r` QTY. ELECTRIC PERMIT FEE
>\ PHGNE�SJ 'I
°AMERACTORs UTLETS-SWITCHES-RECEP 10.00/1.00
uc No. LIGHTING FIXTURES 10.00/1.00
CODDRESS TOR
AAPPLIANCES-RESIDENTIAL 4.00
NTRAS
PHONE IPANELS 10.08 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ADDRESS ENG SPECIAL CIRCUIT 5,00 {ERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH. r
l0W "
SERVICE CHANGE 20.00 G /f;.-7
woo LICENSED CONTRACTORS DECLARATION of Cupertih ( J /
a u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
r z w (commencing with Section 7000)of Division 3 of the Business and
H H i Professions Code,and my license is in full force and effect. MECH.
BLDG. ELECT. PLG.
a v, w W License Class Lic.Number
Date Contrucmr
Q y E J
¢ ¢ w a OWNIi R-BUILDER DECLARATION BUILDING PERMIT
'a oar' MISC.- REFER TO ORD INFORMATION
; LL H I hereby affirm that 1 am exempt from the Contractor's License
u O j Law for the following reason.(Sec.703 L5,Business and Profess ions VgLUATION $/FT.
- g PERMIT ISSUANCE 10.00
le Cprove,Any molish cor ntywhich requires ep riort oconsuane,also aas- Q-O
¢ IS Q O improve,demolish,or repair any structure,prior Ice its issuance,also ELEC.DoNTR, LIC.NO. ELEC. �-
LL respires the applicant for such permit to file a signed statement that TOTAL
e w m he is licensed pursuant to the PERMIT TO
p provisions of the Contractor's License /
HEEa Law(Chapter9(cosions Code)or Section is exeof D ivision3ofthe
F 4 D Business and Professions Code)or thin he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ o the basis for the alleged exemption.Any violation of Svction703I.5 STORE S TYPE CONSTR.
a ;m by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
D 1,as owner of the Property,or my employees wi . .00th wages as BACK FLOW PROTECTDEVICE 4
their sale 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,CON D. 5.00
Code:The Contractor's License Luw does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended Orofferedfor sale.l f,however,the build ing GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build o - .r ice- BUILDING USE
lamoefor Em'Em eof.de.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
LI 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 hadds or improves(hereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractors License Law. SEWER-SAN ITARV-STORM EA.2010.00 TRACT NO. PARCEL NO.
❑ lam exempt under Ser..,B.&P.C.for this
WATER HEATER W/VENT 6.00
rear n
.Ow •r Date WATER SYSTEM
5.00 ACC.GATE ACC.FILE NO.
wOf ER COM PENSA'nON DECLARATIDN WATER TREATING EQUIP. 5.00
I hereby affirm that I have u certificate of consent to self-inmre.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(See.3500.Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished.
Z Z ❑ Certified copy is filed with the city inspection division. FIRE SPRINK ENERGY T-24
F O Applicant MISC.- REFER TO ORD. Y ❑ N0 Y E] NC
!rN CER'f117ICATE OF Ii XEM PTION FROM WO R K E RS' PERMIT ISSUANCE 10.00 FLGODZONE A.L.uc.
LL 2! COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
EL �' (This section need not be completed if (Ice permit is for oneTOTAL V N� V N�
Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of Om work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U out is issued,I shall not employ any person in any manner so as to
Ow become subject to the Worken'Compensalion Laws of California.
G.
Date-Applicant BUILDING �Q (`
} N NOTICE:TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
F ? emotion,you should become subject to tilt workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of tum Labor Code, you must forthwith comply with f�
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE ,Sb
1 hereby affirm ilia( there is a construction lending agency for EXHAUST HOOD(WITH DUCT)
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
Lenders Address HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state iliac the above VENTILATION FAN (SINGLE) 4.00
i information is correct. I agree to comply with all city and county PLUMBING
Ordinances and stale 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 - BOILER-COMP(Over 100,000 BTU)SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupert4this
iabilities,judgments, costs and expenses which CONST.TAX
may ifly as, rue against said City in const mince of the PERMIT ISSUANCE 10.00
gran inni . MECH.CONT. LIG NO. MECH.V TOTAL TOTAL �7
Signatn 'ontraeto D to
OFFICE COPY