8921 POST THIS C D NEAR FRONT OF BUILDING '
PERMIT NUMBER
CITMF CUPERTINO 41- off 89 1
INSPECTION DIVISION
JOB INSPECTION RECORD_
I/APERMIT EXPIRATION
JOB ADD /��I�# PERMIT EXPIRES IF WORK
OWNER CONTRACTOR IS NOT STARTED WITHIN
IN CTI ON DATE INSPECTOR INSPECTIONRECOR 180 DAYS OF PERMIT ISSU.
FOUNDATION aDT� ��6 „ .ANCE•OR 180 DAYS FROM
LIFER
LASTCALLED INSPECTION.
PREGUNITE PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED 46 /j
UNDERGROUND /SLAB f/(� Y/
PLUMBING
ELECTRICAL
ISSUANCE DATE
MECHANICAL _ LD EL T. Plc. MECH. '
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR -
VALUATION $/FT.
PLUMBING - - -
MECHANICAL
1
ELECTRICAL PE mJIT/Tp•
FRAMING =/Z-f W n`�
INSULATION r-11 -kSTCS TYPE CONSTR.
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED -
ROOF — SO.FT.FLOOR PREA TOTAL ACREAGE
DIAPHRAGM -/ BUILDING USE
• HES IND CON PB Other
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED 4 ❑ ❑ ❑ ❑
ROUGH - ASSESSURSPAHCE L NO: li
PLUMBING
TRACT NO. PARCEL NO,
GAS TEST r
MECHANICAL
,ELECTRICAL S 61., FINALS DATE INSP. ACC.DATE ACC.FILE NO.
FRAMING S' G- SAN #
INSULATION " _ PLUMBING - zoNlNc ENc.SITE NO.
GAS
- FIRE SPRINK ENERGY T 2
MECHANICAL Y ❑ NE-1 Y [:] NQ
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATIN
LATH-INTERIOR ELECT ICA FLOODZCNE A.L.U.C.
LATH-EXTERIOR - FIRED PT. Y❑ NE] Y ❑ N❑ •,
SHEETROCK F GRADE FEE SUMMARY
S HEAR INTERIOR BUILDIN
SHEAR'EXTERIOR - �TE ORARY APPROVALS BUILDING r
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 IS SIGNED BY BUILDING INSPECTOR, MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252.4505, ELECTRIC
o�ONE WORKING DAY BEFORE REQUIRED INSPECTION.
PLUMBING
Z .PLEASE GIVE JOB ADDRESS WHEN PHONING:
- SEE PERMIT FOR EXPIRATION DATE - MECHANICAL
CONST.TAX
IMPORTANTI
PLEASE READ REVERSE SIDE BEFORE ie . TOTAL'
CALLING FOR FINAL INSPECTION.
OFFICE COPY
I
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ON Y
BUILDING PROJECT I DENTI FICA PERMITNUMBER
BUILDO APPLICATION & PEF* 8921
'^ piDDfl E55
fn. BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
PLAN CHECK VALIDATION
NAME Corp. OTY. 'ELECTRIC PERMIT FEE
PHONE
�7L
NAME OUTLETS C UTLETS-SWITCHES-RECEP 10.00/1.00
rolls
COr LIC,No. J� LIGHTING FIXTURES 10.00/1.00
ADDRESS }} APPLIANCES-RESIDENTIAL 4.00
tpyp CV/��,,dNEV Q PANELS 10,00 DATE OF APPLICATION
OgcHITECT PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE P.C.N0.
ENGINEER
' sec.NO ISIGNS TRANS. 3.00
F PRESS ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION ,
ZIP TEMP.METER OR POLE INS. 20.00 lig
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
. woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30,00
c v I hereby affirm that I our licensed wider provisions of Chapter 9
O1 (commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE
r '^ Professions CodQand my license is in full R sN4�ef1'epl+� BLDG. ELECT. PLG. MECH.
o License Class L.7Number��.XQ�aI I m
Dale-.K4� -Contractor_1;0JOC[C'
M M X
w a OWNER-BUILDER DECLARATION BUILDING PERMIT
o a INFORMATION
E:
;a w I hereby affirm thst,l am exempt from the Contractor's License MISC.- REFER TO ORD
Hwo J Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 _ VALUATION S/FT.
Code:Any city.,county which requires a permit to construct,alter,
O ,1
QQ Q G improve,demolish,lir rep i,Ilny structure,prior to its Issuance,also ELEC.CONTR. LIC.N0. �V
w aELEC. ,r O N
m rc requires ilicensed
the applicant for such revisit to file a signed actor's i that TOTAL pl
u w he is IIC¢sed Pursuant In the provisions of llse Contractor's License /lPERMIT TO /
riQLaw(Chapter 9(commencing with Section 7000)ofl)ivision 3 ofthe
i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H $ the basis for the alleged exemption.Any violation ofScclion7o31.5 STORIES TYPE CONSTR.
u ; by any applicant fora permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(55000.):
❑ I,as owner of the property or my employees with wages as -BACK FLOW PROTECTDEVICE 400
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,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 sloes such work FIXTURES-PER TRAP 5.00 90.FT,FLOOR AREA TOTAL ACREAGE
• himself or through his own employees.Provided that such improve.
mems are not intended or offered for sale.If,however,the building GAS•EA.SYSTEM-1 I NC.4 OUTLETS 6.00
or improvement is sold within one yearof completion, the owner GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving Ihat he did not build or im- BUILDING USE
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Ouse,
❑ I,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 SEWER-SANITARYV-STORM EA.2001t/70.00
the Contractor's Uc¢mu Law. TRACT NO. PARCEL NO.
❑ I am exempt under See. ,BAP.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent 10 self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy Thereof(Sec.3800,Iab.C.). �s C i�
Pricy No. Company (L� f�
(] ❑ Certified copy iss riledfurnished. _FIRESPRINK ENERGY T-24
Z
Z Cert'led o y is filed with the city inspection division.
� O Ap icaut r MISC.- REFER TO ORD. Yr N0 YC] NE
CC CERTIFICATE Op EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00
FLOOD ZONE AL.u.C.
lL COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section need not be completed if the permit is for one TOTAL Y❑ N El Y ❑ IN
::� Z hundred dollars(S 100)or less.)
V O I certify that in the performance of the work for which this per- OTY. AL PERMIT FEE FEE SUMMARY
MECHANIC
LL U mit is issued,I shall not employ any person in any mannerso as to
become subject to the Workers'Compensation Laws of Callfornio.
D_ Data ApplicantALTER OR ADD TO MECH. 5.00 BUILDING (Fd S
>_ s
to NOTICE TO APPLICANT: If,after making this Certificate of Ex- .�.
F Z emplion.you Should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with U FEE such Provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=1C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p000.F.M.) 6.00 SEISMIC FEE 20
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's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC 00.
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• BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING ordinances rad state laws relating to building construction, and
hereby authorize representatives for ins 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 in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
nti of this pe{n' MECH.CONT, LIC,NO. MECH.
%1It� TOTAL TOTAL �/ e
Ignature Ap icant/Contractor Date
OFFICE COPY