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1653 CITY OF CUPERTINO APPLICATION FOR RESIDENTIAL BUILDING PERMIT PERMIT NUMBER (�s3 ' AND FOR APPLICANT TO FILL IN CERTIFICATE AND OCCUPANCY BUILDING INSPECTION DIVISION L ST OtPAJE G7, - • • , . • Legal Description: Tracct.... . ...... ........ @lock............ Lot...................... Descri Ption of Work: ...�L�. F2..!_Ci'...,........79:2...AFF....._. PlansReceived By. ........ .................................... Date ......................... .. ... . REO.: Plans.... Survey .. Cafes: Strut. .. Energy.... Elect. Mach.... tat Strutt. Improvement on Parcel:Yes No Area ..Area of Bldg... ..... .. Plans Checked By................�.1.... Date ............... ..... Separate Structure.____... or Addition/Alteration to Exist. Bldg........... Application Approved By... Date Date X1-.,5-.FJ. No. of Stories..... U of Building ValidatedB �.....__....... __...... ssee,� g ............_.... _........_..._...._........ By..............................................................Date ........................ ,'Valuation o���f,,,Prrrroject: $._-..3 7PQ..d�......_............ a..:71 .� Compensation Certificate Verified By ...... ......_. Date ......_...... ,_., .Owner .../{2� 3.E$T.LITtFIt ...._._ .....,,. PF�One[ - 9r...: .ro Contractor: /l'gCe- �ooFZ.NC> City Bus LIc x 113IMMelli $ 39&) i Contractor's Address 32.9 4lNN1FR fS Phone2$t$- 4o3i. Permit Fee (plus penalty f applicable) Contractor - Electrical: ... ._. .__.-_. . ......... ...... (P P e i PP ) ..............._.......$ --- -'.�... City Business License a..____.__..... Phone:.__............... Plan Check Fee (less deposit of$......�irR t- . .....)0...................... Plumbing: r g .................. ..... ct. G:il i41...................... g: Strong Motion Fee ...._...... . 1�} City Business License fe.....__._...__. Phone:.................... Energy Plan Check Fee (Dep. of Plumbing Permit Fee ...� q Heating and Cooling .__......__......._...._......_._......................_. ..chJ........1...�A. _.............._..... City Business License 0...... Phone:.................... Mach.Electrcal Permit Fee ......it $............_................_..:.:..r..$.._............._..: Architect/Designer: _ ......._._ Phone:.................... Mach. H[g./Caolg. Permit $............-, ------_ ,1..It...�... $ .__. Engineer: ... .... - _.... .......__ Phone: ..Un Residential Construction Tax . -------- ---- $ "' Lender: .. ... . . - E] Unknown Misc. Fee .......... ............. .................. _....... .._........ ....... ... ....... "I certify that in the Mise. Fee t� ],, Y y any person of the work for which this permit Is """"""""""-""""'-"""""""�"�'M.""-��$�������`���•���� issuetl I shall not employ any person in any manner so as to become subject • $2 to the workman's compensation laws of California." 3 SIGNATURE OF • • APcP�LICANT/OWNER ..............._._._.....__......._._................. _.._ DATE........................ Environmental Status: Exempt............ Other................ IJ -certify that as the applicant I am licensed unde the rout ions of the Design Review Approval: Bldg. _.._...... Site .._.._.... Sign .._........ Contractors license aw and further that my Licens. No U.321.9........... Use Zone ............ P.D. Conditions ................ . _... ........._.... in Classification .....C.75lit.........-..__ is in full force and effect: or Cond. Use Permit a............ Variance #............ Parking Spaces........_.. . .. I certify that I am exempt from the "Licensed Required" provisions of the Approved B Contractors License Law. (State basis of exemption.) pp y._.....__........._........................_...._... Date ...._._._...__........ ` I hereby acknowledge that I have read this application and state that the above to PUBLIC UIREMENTS !orrect and agree to comply with all City Ordinances and State Laws regulating WORKS ' building. I (We) agree to save, Indemnify and keep harmless the City of Cupertino croachment Permit.................__.. Grant of Easement. ....... against liabilities, judVIORL., cos d e race which may in any way Orb, Gutter, Sidewalk, Driveway: Replace.......... Repair.......... acture against said Cit n nseof c o t e gran ing of this permit." Sewer............ COM. Fee $....... Water................ Meter $................ SIGNATURE OF Agreement for Completion Of Public Works Improvements .....__......... APPLICANT/CONTRACTOR ... ._ ... _......... DATE ..1.. .I_........ Plans Checked By........ Date........ Approved By........ Date........_._..... NOTE: When properly validated This form constitutes a Building Permit. This permit expires and becomes null and void should work not,be commenced within APPLICATION • 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 APPLICATION FOR PLUMBING PERMIT Light Outlets............ Switches....... _ 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. Trey..................... 4.00. Greater than 1 HP 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 1...................................................... Vacuum Breakers ...........................-................ ..............3.50.............. NOW Residential Occupancies Flat Rate Interceptor........ Water Softener........ ... ..4.00. . Plumbing Piping without fixtures ...................................4.00, .............. 0-500 sq. ft. $22.00 1501-1750 $34.50............................... Mist. (See Ord. Current) .......... 501-760 24.50 1751-20000 37.50.............................. .......................................... PermitFee ..........................................................................$ 6.00 751-1000, 26.00 2001-2250 39.50.............................. TOTAL PLUMBING PERMIT FEE (plus penalty it app.C7) $ 1001-1250 28.60 2251-2500 42.00.............................. 1251-1500 32.00 2501-2750 49.50..:........................... I APPLICATION FOR HEATING/COOLING PERMIT PermitFee...............................................$6.00 TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.Cl) $ PERMIT INSTALLATION NO. EACH FEE _ Forced Air Unit..................to 100M ..............................$ 6.00............... over100M ................. ...... . 10.00.. ........... f Comfort Cooling Unit......to 3 ton/HP ................. .......... 6.00............... Forms / Foundation ................._........... By:....... . ..... Date:................ to 15 ton/HP......................... 9.50 .......... Plumbing Ground Work . .............._.._ I..... _..._.__....._..._._____._...__ to 30 ton/HP...........................12.00. - . ........... Rough Electrical ......--_..._..._......_...._ .... .................... .................:......... to 501on/HP_.........................17.00.............. line Plumbing and Heating 1 .... ... ... .. Space Heater........ Wall Heater . .. . 6.00.,..............ulation $ Energy................. _.. ... - -. Flues - other than above 3.00 s Test " ... ���-����� ��� -- Vent Fan: Kitchen.... Bath 3.00_4__ Temporary Power Gas / Elect ..._ .l- -.. Commercial Range Hood __ _ {Ir OD Final - Electrical . - . . - .�.. „ Misc. (See Ord. Current. . _. L 6 �p Final -`Bulldm / Mechanical / .I..S '�� .SC-. permit Fee -. .... $ 6.00 Final - De ' eview / Landscaping . .... _.._ . ...___... TOTAL Htg./ Coolg. Permit Fee (plus penalty if app. ❑) If Final- Public Works ........................................................... Sheet 2 OF CUPERTINO BUILDING PER14I! Permit No: &S-3 Address: CJ ;?/0 Date: 11 -2 BUILDING PROJECT IDENTIFICATION WORKERS'COMPENSATION DECLARATION Applicant's Mailing Address I hereby affirm that f have a certificate of consent to self-insure. or a c thereof of Workers'Compensation Insurance,or a certified Address of building copy thereofof (Se< 60(1,_Mb.C.,. �0o'cy No. Cumpany , Certified co vis hereby furnished. Owner's name P. Certified copy is filed with the county building inspection Telephone Na. department or county Contractor's Name j"KC CC) QpJ f, . . Date .Applicant department Contractor's Mailing Address LA.- J' CERTIFICATE OF EXEMPTION FROM WORKERS' C No. COMPENSATION INSURANCE Architect or Engineer (This section need not be completed if tjse permit is for one Architect's or Engineer's Address hundred dollars (s100) or less I - I certify that in the performance of the work for which this permit Lic. No. is issued,)shall not employ aqv person in any manner so as to become subject to the Workers' Compensation Laws of California. LICENSED CONTRACTORS DECLARATION Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of I hereby affirm that I am licensed under provisions of Chapter 9 Exemption, you, should become subject to the Workers' (commencing with Section 7000) of Division 3 of the Business and Compensation provisions of the Labor Code, Professions Code, d license is in full force and effect ),on must forthwith - > 19 comPlywith such provisions or this permit shalfbedeemed revoked. License Class Lic. Number ' Date Contractor S Co eooFJ.-,` CONSTRUCTION LENDING ACENCI' 1 hereby affirm that there is a construction lending agency for the Performance of the work for which this Permit.is issued (Sec.3097, O\VNER,BUILDER DECLARATION Civ.C.). Lender's Name ------------ 1 hereby affirm that I am exempt from the Contractor's License Lender's Address • Law'for the following reason (Sec.7031.5, Business and Professions i Code: Any city or county which requires a I certify that 1 have read this application and state that the above improve,demolish, 9 Permit to construct,alter, information is correct. I agree to comply with all city and county P or repair any structure,Prior to its issuance,also ordinances and state laws relating to building construction, and i requres the applicant for such permit to file a signed statement that y authorize representatives of this county to enter upon the he is licensed pursuant to the provisions of the Contractor's License hereb Law (Chapter 9(commencing with Section 7000)of Di%ision3 of the above-mentioned property for inspection purposes. Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 Sigoarare of APPtcaot or Agent pale by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ❑ 1,as owner of the property,or my employees with wages as 'OWNER-BUILDER VERI their sole compensation, will do the work,and the structure is not FICATION intended or offered for sale (Sec. 7044, Business and Professions "Attention Property Owner: Code: The Contractor's License Law does not apply to an owner of ...At 'owner-builder' building permit has been applied for in property who builds or improves thereon,and who does such work your narim mid bearing your signature. himself or through his own employees, provided that such 'Please complete and return this information in the envelope improvements are not intended or offered for sale.If,however,the provided at your earliest opportunity to avoid unnecosary delay building or improvement is sold within one year of completion,the inoceming and issuing your building permit No building permit owner.builder will have the burden of proving that he did not build will be issued until this verification is received. or improve for the purpose of sale.). 1. 1 personally plan to provide the major labor and materials for ❑ 1,as owner of the property,an%exclusively contracting with . Construction of the proposed properly improvement (yes or no) licensed contractors to construct the project (Sec.7044,Business and Professions Code: The Contractor's License Law,does nota I to 2 1 (have/have not) signed apply - gned an application for a an owner of property who builds or improves thereon, and who building permit far the proposed work contracts for such Projects with a contractor(s) licensed pursuant to 3. 1 havecontracled with the following person(firm) to provide the Contractor's License Law.), the proposed construction: ❑ I am exempt under Sec. , B.&P.C. for this Name reason Address City. Date Owner Phone Contractors License No. 4. 1 plan to provide portions of the work, but I have hired the following person to coordinate,supervise,and provide the major works Name Address City Phone Contractors License No. 5. 1 will provide some of the work but I have contracted(hired) the following Persons to provide the work indicated: Name Address Phone T . ype of Work . Signed: Property owner Social Security number Date: