09670 (2) POST THIS CARD NEAR FRONT OF BUILDING
• PERMIT NUMBER
CITY OF CUPERTINO :, . 7
` INSPECTION DIVISION
JOB INSPECTION RECORD
h —1 •s PERMIT EXPIRATIONz'
JOB ADDRESS/. l;2�(Q 7Cleai- GK . 0 - '
UNIT# LOT#,
PERMIT EXPIRES IF WORK
• OWNER D CONTRACTORLAQ705 - - IS NOT STARTED WITHIN ,
INSPECTION DATE INSPECTOR INSPECTION RECORD' 180DAYS OFPERMIT ISSU-
ANCE OR 180 DAYS FROM
f
LAST CALLED INSPECTION.
UFER
PREGUNITE '• - - _ PERMIT VALIDATION
ay
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED K
UNDERGROUND /SLAB -
PLUMBING
NDERGROUND /SLAB PLUMBING
ELECTRICAL- ISS ISSDANCE DATE
MECHANICAL - - BLD < ELECT. PLG. MECH.
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED - , BUILDING PERMIT
WOOD FLOOR INFORMATION
PLUMBING _ VALUATION- $/FT.
MECHANICAL
ELECTRICAL - CCvERMrt ro
FRAMING - J /
INSULATION ' STORIES TYPE CONSTR:
4
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF SO.FT FLOOR AREA TOTAL ACREAGE
1 .
DIAPHRAGM
'BUILDING USE '
INDCON PR Olney
' APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ 0 O
ASSESSORS VAflCE L NO.
ROUGH
PLUMBING
GAS TEST, TRACT NO..' PARCEL NO.
t
MECHANICAL -
ACC.DATE ACC.RLE NO,
ELECTRICAL FINALS DATE INSP.
FRAMING SAN * -
ZONING' ENG.SITE NO. '
. INSULATION � PLUMBING -
GAS
MECHANICAL FIRE SPRINK ENERGY TQA
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Yo NE] Y ❑ IN❑
LATH—INTERIOR ELECTRICAL - FLOOD ZONE - aL.u.c.,
LATH-EXTERIOR FIRE DEPT. r�., ,N� v� N❑
SHEETROCK' GRADE" FEE SUMMARY
SHEAR INTERIOR - BUILDING
SHEAR EXTERIOR - 'TEMPORARY APPROVALS, - BUILDINGt,-
FIREWALLS . ELECTRIC PLAN CHECK
GAS .FEE
• NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY - .SEISMIC FEE
OCCUPANCY OF BUILDING ISNOT PERMITTED UNTIL BUILDING FINAL ISSIGNED By BUILDING INSPECTOR. ~ '
- MICROFILM
Lu ARRANGE FOR INSPECTION BY PHONING 252-4505ELECTR
,. , IC e -
ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
0 PLEASE GIVE JOB,ADDRESS WHEN PHONING.
J
Z SEE'PERMIT.FOR EXPIRATION DATE - MECHANICAL
IMPORTANT.!.: CONST.TAX ,
PLEASE READ REVERSE SIDE BEFORE TOTAL f
CALLING FOR FINAL INSPECTION.
OFFICE COPY -
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POI T PEN ONLY
BUILDING PROJECT IDENTIFICATION - , PERMIT NUMBER
r
DING APPLICATION & PERMITOng�0
R S . `� IBUILDING-ELECTRICAL-PLUMBING-MECHANICALER' PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE
"It
IX
PHONE � , 7�
'NANe A.TDR's UTLETS-SWITCHES-RECEP 10.00/1.00 OC
Loxes osul=.ND.3l
LIGHTING FIXTURES 10.00/1.00
ADDRESS TDR's ^�, PPLIANCES-RESIDENTIAL4.00
2S �tvLn PHONE -2 PANELS 10.00 DATE OF APPLICATION
ORR=HITI:cT PANELS(OVER 200 AMP) 20.00 _PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No, ISIGNS TRANS. 3.00
ADDRESS eea. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
APLICANT'S ZIP EMP.METER OR POLE INS. 20.00 l'N
P
AUUfless MOTORS /r SEE FEE SCH.
SERVICE CHANGE
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
H
w u 1 hereby affirm that I am licensed under provisions of Chapter 9 C E
y a w (commencing with Section 7000)of Division 3 of the Business and LD CH.
L, D z Professions Code nd m icense is in full fosGC ynd•nff�c. ❑
z i o License C Lic.Number 61�7C D
2 r Dale ContractorSQtd.�!y�+ 10 0 6rm 0
� :
a ma OWNER-BUILDER DECLARATION BUILDING -
0 i U - INFORMATION
X ; w I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION
u O a Law for the following reason.(Sec.7031.5•Business and Professions Q
H PERMIT ISSUANCE 10.00
Code:Any city or county which requires permit to construct,alter, i
Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.N0. ELEC.
wDLL requires the applicant for such permit to file a signed statement that TOTAL ` PERMIT TO
m he is licensed pursuant to the provisions of the Contractor's License
H z a Law(Chapter 9(commen6ngwilb Section 7000)of Division 3 ofthe
f 4 D Business and Professions Code)ear that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
X $ the basis for the alleged exemption.Any violation of Section 7031.5 STOFfftwS PE CONSTR.
by any applicant for a permit Subjects the applicant ton civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
_ of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 Oce.GROUP RES.urvlis
their sole compensation,will do the work,and the structure is not
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 t0 an owner of
property who builds or Improves thereon,and who docs such work F IXTUR ES-PER TRAP 5.00 SG,FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve-
hmentsimse are not Emended or offered for sale.if,ehowever,d that s the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 8.00
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have lite burden of proving that he did not build or im-
prove for purpose of Sale.). IND CON PB Other
❑ 1,as owner of the property•am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project(Sec.7044,BusinessLAWN SPRINKLERS-1 INC5 V.B. 6.00 ASSESSORS PARCELNO.
and Professions Code:The Contractor's License Law does not apply
t0 an owner of property who builds or improves thereon•and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts foprojects with a contractoRU licensed pursuant to
the Contractor'sur's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
L
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER WIVENT 6.00
reason
Owner Dale WATER SYSTEM PAI 0 5.00 S-1&
ACC.GATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE N0.
I^ or a certificate of Workers'Compensation Insurance,or a certified 1983
X l copy thereof(Sec.3800,Lab C.).
b1T�
Policy No. Company .{
❑ ledcopy ishe furnished. Q'`IO FIRE SPRINK ENERGY T24
Z Z Certi it i speclbn division.
p Applican MISC.- R ER TO ORD, v ❑ N❑ v ❑ Fa[]
~ ua PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU CERTIFICATE E SATIOTINS FROM WORKERS' d
W COMPENSATION be
PLG.CONTR. LIC,NO, PLG. LU yO N❑ Y❑ N❑
Z (This section need not be completed if the permit is for one TOTAL
hundred dollars(8100)or less.)
U O I certify that in the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL F mit is issued,I shall not employ any person in any manner so i s to
O.W become subject to the Workers'Compensation Laws of California. BUILDING
ALTER C 6
y
Date-Applicant OR ADD TO MECH. 5.00 J
>- ED NOTICE TO APPLICANT: If,after making this Certificate of Ex-
L. ? ensption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with -7- FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,OMC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10PMC.RM.) 6.00 SEISMIC FEE fiO
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WI ) 5.00 .
309 performance 7. of the work for which this permit is issued(Sec. HEATING UNIT(TO 1 ,0 0 B.T.U.) 8.00 MICROFILM
Lender's Nam, HEATING UNIT IDYE 1 OB.T.U.19.50 ELECTRIC
Lender's Address
( I certify that I have read(his application and state that the above VENTILATION F IN L 1 4,00 OZ/
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP( (H.P.or 10 -nUlP 6.00
hereby authorim representatives of this city to enter upon [he (- dV
above-mentioned property for inspection purposes.
BOILER-COMP IOuar , oO Bru)gEE FEE SCH. MECHANICAL D
(We) agree W� emriand keep harmless the City of MISC.- REFER TO ORD.
Cupertino agaiants, cotsand expenses which CONST.TAXmay inaid City in consequence of the PERMIT ISSUANCE 10,00
g g Of MECH.CONT. LIC.NO. MECH.
S PS TOTAL SSA TOTAL
r o p manl/Contractor ate r
OFFICE COPY