1776 • CIIt OF CUPERTMO •
CITY OF CUPERTINO PPLEMEN AL
APPLICATION FOR RESIDENTIAL BUILDING PERMIT L PERMIT NUMBER
• AND FOR APPLICANT TO FILL IN
CERTIFICATE OF OCCUPANCY RA
BUILDING INSPECTION DIVISION STREET ADDRESS OF PROJECT:
.... ._10240_Anthony..-P.lace............ ........................._..._...........
r • Legal Description: Tract.........6.551.... Block............ Lot. .6................
Description of Work: ...... ._.... ..__ _........................._..................
Plans Received By....................................._............Date ........._.............. .........._.....__.--._.._..__....__.S olar...permit
REO.: Plans.... Survey.... Cales: Struc..... Energy.... Elect..... Mach.... 1st Struct. Improvement on Parcel:Yes.... No.... Area of Bldg...............
Plena Checked By..........................................._......Date .................. Separate Structure.........._ or Addition/Alteration to Exist. Bldg...........
Application Approved By......................................... Date ......................... No. of Stories................ Use of Building ..................._._.........................
Validated By..............................................................Date ........................ Valuation of Protect: $.
Compensation Certificate Verified By ....... Date ........................ Owner: __............_____...._..........._.._..........._......... Phone:....................
• •
Contractor: ....HAS--HOMES-.....I1TC.........-City Bus. Lic. # ._......
lwvmm _...
• • $ Contractors Address: _...
_....... ...._......_.............. Phone:...................
Permit Fee (plus penalty if applicable) ............... $.24...@0...._... Contractor - Electrical: .... _
..... ....._...__....... _
..._........._...... ........
.........
Plan Check Fee (less deposit of$.......... Rct. #..... $....................... City Business License #_........._....... Phone:....................
Plumbing:Energy Plan Check Fee (Dep. of $........ Ret.
.._...........)$._...._..... City Business License #............._..... Phone:....................
Strong Motion Fee ..__..._._...._._...................._........._..$..-_._,r ..... Heating and Cooling
..................................................................
Plumbing Permit Fee ................................................$.../f7-.:!)"f!....
Electrical Permit Fee ..._..... .. ........ .....__......... ___$.... .................. City Business License #_...._... ...... Phone:....................
Mach. Htg./Coolg. Permit $.......:...... "•"' ....... ................ $...... . Architect/Designer: ....._...... ........_.._......___..._..... Phone:....................Residential Construction Tax . . - . -....... .........$ .._.......... Engineer: ��--- -
..........__ ......... Phone: _.... .........
_..
Misc. Fee ............ ...........................................................$.............. Lender......,. . .._.._ . .. _ ..... .............. ❑ Unknown
Misc. Fee "'""" """"""'""'"""'"""'"" """"""""""$"""""-""---"" "I certify that in the performance of the work for which this permit Is
"""'"" - " issued I shall not employ any person in any manner so as to become subject
• $ 24, 50 to the workman's compensation laws of California."
SIGNATURE OF
• ! APPLICANT/OWNER .......... ....... ....... DATE.
Environmental Status: Exempt ............ Other......:.........._.................... I certify that as the applicant I am licensed unde the provisions of the
Design Review Approval: Bldg. ............ Site ..._._.... Sign ............ Contractors License Law and further that my Ucens, No. .....
Use Zone P.D. Conditions in Classification ........ _..._..................... Is in full force and effect: or
Cond. Use Permit #... Variance #...__..... Parking Spaces............ I certify, that I am exempt from the "Licensed Required" provisions of the
Approved H .
pp y.:.._........_....._..............__..._...__.._ Date ._............_..._..._ Contractors License Law (State basis of exemption.)
i hereby icknowledge that I have read this application and state that the above Is
:orrect and agree to comply with all City Ordinances and State Laws regulating
building.
�OCfOBChmBnt Permit....__...__........ Grant Of Easement ....... I (Wei agree to save, Indemnify and keep harmless the City of Cupertino
against liabilities, judgments, costs and expenses which may In any way
urb, Gutter, Sidewalk, Driveway: Replace.......... Repair.......... occurs against said City in consequence of the granting of this permit."
Sewer............ Conn. Fee $.-___._..... Water........._ .. Meter $_..........__ SIGNATURE of
Agreement for Completion of Public Works Improvements .................. APPLICANT/CONTRACTOR _.._......................._......_............_.. DATE ..........
Plans Checked By...__. Date....... Approved By.__... Date__......_.__... NOTE: When properly validated this form constitutes a Building Feel This
permit expires and becomes null and Vold should work not,be commenced within
• • 120 days from validation date, or should authorized construction be suspended or
abandoned for a period of 120 days after work is commenced.
PERMIT INSTALLATION NO. EACH FEE
Light Outlets___.__.. Switches............ APPLICATION • • PLUMBING
Fixtures...-:....... Receptacles............ PERMIT INSTALLATION NO. EACH FEE
TOTAL NUMBER (less than 1000 watts) ._..___. $ ,50 - -- Gas System with up to 5 outlets .................................$4.00 .............
Range.. .. Cooking Unit_..... Oven............ .. ....... 2.00 .. ............ Each additional outlet ............................................. 1.00...............
Dryer........ Garb. Disp......... Dishwasher ............. ........ 2.00 .............. Water System (Installation, Alt. or Repair) ................. 4.00...............
MOTORS: 1 HP or less ..............._.................. ..... ....... . 2.00 -- - Water Closet.... Water Heater.... Ld. Tray......:- -_- -_ 4.OU. ---.........
Greater than 1 HE not more than 5 HP .............. . 3.50 .............. Lavatory.... Shower Pan.... Bathtub.... Sink................... 3.00...............
Temporary Power Pole or Service — 100 amp .......-..5.00 .............. Wash. Mach..... Dishwasher.... Garb. Disp..... ............... 3.00...............
—200 amp.___. 7.00 .-............ Sewer ........_......................................_.................:.......... 8.00...............
Time Clock _....._..__..............._.._....__..........._.._.......... 1.50.....-......... Lawn Sprinkler Sys. $5.00 Ea. add Sys. $2.00..................... .............
Misc. (see Ord. current)...................................................... Vacuum Breakers ........................................... ..............3.50.....:........
New Residential Occupancies Flat Rate Interceptor........ Water Softener........ .................4.00. ............
0-500 sq. ft. $22.00 1501-1750 $34.50........... Plumbing Piping without fixtures ............................ ....4.00-,,,,,,,,,,,,,,
•............•••••• Misc. (See Ord. Current) ..SA.LdS..A2Y,10� ........4..Q
501-750 24.60 1751-20000 37.60.............................. 6.00 ••
751-1000 26.00 2001-226C 39.50.............. Permit Fee .............................(plus"p-..............-a-p'............$ 8.00
1001-1250 28.60 2251-2500 42.00.............................. TOTAL PLUMBING PERMIT FEE (plus penalty if app. �) _
1251-1500 32.00 2501-2760 49.50.............................. APPLICATION •- HEATING/COOLING
Permit Fee...............................................$6.00
TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.Cl) $ PERMIT INSTALLATION NO. EACH FEE
Forced Air Unit................_to 100M ..............................$ 6.00,..............
INMMEM
• • ' ' over 100M ........................ . 10.00.. ...........
Forms / Foundation ........... ... . B _.... . Date:................
Comfort Cooling Unit....Ao 3 ton/HP ........................... 6.00...............
Plumbing Ground Work .._ j ... .. .. .......
to 15 ton/HP....................... 9.50....:..............
to 30 ton/HP............... .. 12,00. ............
Rough Electrical .. _... _. .. - . ..._. to 50 ton/HP.... ......... . 77.00..........
fame - Plumbing and Heating ..... ... -- Space Heater........ Wall Heater . ........ 6.00„,-.......
sulati on & Energy .... _ ......... (.. .... Flues - other than above .. .. 3.00 as Test -- ..... Elect.
� Vent Fan: Kitchen .. Bath ( 3 00
Temporary Power Gas /Elect ... --- ...' Commercial Range Hood _ - ... _ 6 00
Final - Electrical .. ... .... ..... ... - Misc. (See Ord. Current .. .._ _ _-
.... ... ............
Mec
Final - Design
Building /Review
/ Landscaping
._... I .. - .. Permit Fee .... ... $ 6.00
Final - Design Review / Landscaping ..... .. .. TOTAL Htg./ Coolg. Permit Fee (plus penalty If app. ❑) $
Final-Public Works ...........................................................