17666 POST THIS CARD NEAR FRONT OF BUILDING PERMIT NUMBER
CITY OF CUPERTINO
INSPECTION DIVISION
JOB INSPECTION RECORD
PERMIT EXPIRATION
JOB ADOR ESS ' y ��Ill�rt L'�uNIT# LOT# -
PERMIT EXPIRES IF WORK
OWNER CONTRACTOR U w vl _ IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION ANCE OR 180 DAYS FROM
NOTE:
LAST CALLED INSPECTION.
UFER ALL GRADING AND DRAINAGE SHALL BEI INSTALLED
PREGUNITE TO COMPLY WITH THE APPROVED PLANS AND CITY OF - PERMIT VALIDATION
CUPERTINO STANDARDS.
GARAGE SLABS
II POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB
PLUMBING
ELECTRICAL- - - ISs ANCE DATE
MECHANICAL BLDG. IL" vLc� MEG.
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR VALUATION $TT,
PLUMBING
MECHANICAL Hp�
ELECTRICAL (jam ,66,, ON MOO - PERMIT iO
FRAMING
INSULATION X95 cam" /o c STORIES TYPE CONSTR
GROUP RES UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
SO.IFT FLOOR AREA TOTALACREAGE
;.- ROOF - NOTE:NO FINAL INSP.SHALL BE�MADE BEFORE
DIAPHRAGM THE CONSTRUCTION TAX IS PAID '
BUILDING USE
ROOF SHEATHING RES IND CON PB 0'1-
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP. 0 ❑ ❑ ❑ 11
ROUGH SAN.q ASSESSORS'PARCEL NO.
'
PLUMBING — f ELECT.ENERGY
6S
TRACT NO. PARCEL NO
Tu8sHOWER AN - PLUMBING ENERGY
MECHANICAL - MECH.ENERGY
ELECTRICAL � - BUILDING ENERGY ACC.DATE ACC FILE NO
FRAMING. ELECT.FINAL TEST
�. INSULATION PLUMBING ZONING ENG.SITE NO.
GAS TEST GAS
MECHANICAL FIRE SPgINK ENERGY LN
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING " ° C
I EXTERIOR SHEAR ELECTRICAL RELEASE - FLOOD ZONE A UC
INTERIOR SHEAR FIRE DEPT.
^` ❑ NE) YI✓ NO
SHEETROCK GRADE FEE SUMMARY
'EXTERIOR LATH BUILDING
I
INTERIOR- LATH TEMPORARY APPROVALS BUILDING
SCRATCH COAT - ELECTRIC PLAN CHECK
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
ECCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR, MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
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
BUILDING APPLICATION & PERMIT
. ADDRESS S„ 17666
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
Ow ER'S PLAN CHECK VALIDATION
NAME PHON CITY. ELECTRIC PERMIT FEE
•
NAMEA TORS OUTLETS-SWITCHES-RECEP 10.00/1.00
A V (jq o. LIGHTING FIXTURES 10.00/1.00
CONTRAO
P 's
R�E155 APPLIANCES-RESIDENTIAL 4.00
��T,1
�/� (� C 1 PHONEPANELS 10.00 DATE OF APPLICATION
ARCHITECT - PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
EMP.METER OR POLE INS. 20.00
21P J
AMV1 1-Mit
SS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 4124/gfl
O a i
r O D LICENSED CONTRACTORS DECLARATION
a v I hereby affirm.that I am licensed under provisions of Chapter 9 ISSUANCE DATE
r "'A (commencing with Section 7000)of Division 3 of the Business and AR-tv
of 6 vi ELECT. PLG. MECH.
O ZOO Professions CoJearsn license is in full fore Qfec. .Z ❑ ❑
Z o y - License CL7TasLs Jyr/,d Lia Number ,.1j b
Date Comrucmr
a x f , 10140f Cup rtinoBUILDING PERMIT
at ,x w 4 OWNER-BUILDER DECLARATION
O A o - INFORMATION
E:
; LL y 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u. 04 Law for the following reason.(Sec.703 1,5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION SIFT.
�, 0 Code:Any city or county which requiresx permit loconstrucL a ter,
ac ¢¢O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
D u requires the applicant for such permit to file a signed Statement that TOTAL xf--yf`uPER MI�TT
�(
w m he is licensed pursomirto the provisions of the Contractor's License ` E9✓1 N
ac z a Law(Chapter9(commencingwilli Section 7000 of Division3of the
f 4 O Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
I-a the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CON TR.
w- by by any applicant for a permit subjects the applicant toe civil penally 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 FLOW PROTECT. DEVICE 4.00
their sole compensation,will do Ore work,and the structure is not Oec.GROUP RES.UNITS
intended or offered for sale(Sec'. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 �p
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 ,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided flint such atimprove- GAS-EA.SYSTEM-11NC.4OUTLETS 6.00 improve-
means are not intended or offered for sale.If,however,the building
or int P, venent is sold within one year of completion,the owner GAS•EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the harden of proving That he did not build or inn-
provefor purpose ofs;de.). - INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
O I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project ISec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
and Professions Code:The Contractor's License Law docs not apply ASSESSORS PARCEL NO.
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OV ER 5(EA.) 1.00
contacts for such projects with a contmctorfsl licensed pursuant to
the Contractor's license Law. I SEWER-SAN ITARV-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sea ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK F-RS'COMPENSA'fION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificateof consent to sellcinsum, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished.
FIRE SPR INK ENERGY T$4
Z Z ❑ Certified copy is fled With the city inspection division. MISC.- REFER TO ORD.
O Applicant V [-] N❑ V [:]. N[] '
1- rn PERMIT ISSUANCE 16'.99
LU > CF:RTI FICCOI TFNSABION ION FROM WORKERS' 0-0 ZONE A.L.u.C.
LU
0 COMPENSATION INSURANCE PL a NoL82 TOTAL ❑ ❑ ❑
(This section need not be completed if the permit is for one Y N Y N
Z hundred dollars(SI00)or less.)
U O 1 certify that in the performance of the work for which this per; OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL Vol Is issued,I Shall not employ any p on in any ma r so us In
O becom�syyb,.�1Fc��t to the Workers'Con .vat' L n
U a USte_JYJf�Applicant - L'/fes ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICF TO APPLICANT: 1 , ma ing us Cert ific e o
F 2 coalition,you should become subject to the Workers Compensation APPLIANCE 5,00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply wit11 - FEE
U such provisions or this permit shell he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
1 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), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender Name H EATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and slats: laws relating to building construction, and BOILER-COMP(3 H.P.of 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
it above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTUI SEE FEE SCH. MECHANICAL
(We) agree to save, indemnity and keep harmless the City of MISC.- REFER TO ORD.
Cupertino a trial liabilities,judgments, costs and expenses which CONST.TAX
may in an accrue against sa' C'ty in consequence of the PERMIT ISSUANCE 10.00
noting to MECH.CONT. LIC.NO. MECH. �aPY
O.7-D TOTAL TOTAL:
more of App mant/Contractor Date T�
OFFICE COPY