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1839 CIT( OF. CUPERWAO • PERMIT NUMBER LEI FOR APPLICANT TO FILL IN IM1 _ STREET ADDRESS OF PROJECT: Plans Received By...........-.......................................Date ....................-... Legal Description: Tract........................ Block............ Lot...................... REO.: Plans.... Survey.... Calcs: Struc..... Energy.... Elect..... Mach..... Description of Work: Plans Checked BY - ---- -- -.............-....Date ............ tat Struct. Improvement on Parcel:Yes.... No... Area of Bldg............... Application Approved By.........................................Date ..............__......- Separate Structure_.......... or Addition/Alteration to Exist. Bldg........... Validated By...............................:............._.........-...Date ........................ No. of Stories................ Use of Building _..................-............................. Compensation Certificate Verified By....................Date ............. .... Valuation of Pro'ect: $...__.__... • • • $ Owner: .,fid{..D. .R.L.ICH_..REALTY.._....:........ Phone:2Y-.9...q5 S Permit Fee (plus penalty f applicable) Contractor: --00A)E&............. City Bus. Lic.#_.........................._. (P P Y i t ) ..Rct................$..-.............._... Address: ..........................-_.........--..........__..-......._.-.. Phone•J.:................. Plan Check Fee (less deposit of$... Rct. #..........)$_.........._...._... Contractor - Electrical: ..._...__._..._.......... ................. ._.....-..._.............. Energy Plan Check Fee (Dep. of $........ Rct. #........) S.-................... City Business License #.................... Phone:.................... Strong Motion Fee ......................._................... ....._...$.............._...... Plumbing: Plumbing Permit Fee $...._........_.._... _.....__...Lice...e #._..............._.......ne:.................... ..........._._.._...........__...._._... City Business License #................_.. Phone:.................... Electrical Permit Fee .............................._........._......... $..7.<.O'd...... Heating and Cooling ........... ................................ .................... Mach. Htg./Coolg• Permit $ ..............................$...................._ City Business License #.................... Phone::.................... Construction Tax.............................................$............. ......... Architect/Designer: Phone:.................... Sewer Conn. Fee .............. Water Conn. Fee ... ..........$................_.... Engineer: Phone:................. Landscape Fee ._..........._.... Street Tree Fee ..........-$__........._....— Lender: _.._,__.._...__...........D� Unknown ....................................................... Mise. Fee ....._............................_......___.......................$.__...-- -------- •'I certify that In the performance of the workfor which this permit Is • • . . ; $ Issued I shall not employ any person in any manner so as to bpcc a au to the workman§cc ensatlon laws of Cellfornia.':-v bw'_ '/'� Type Const......... Group........ Div.... .. Occ. Load........ No. Exits........ SIGNATURE OF 57-$-1 Floor Loads: 1st.... 2nd.... Other..-. Sprinklered.... Area Sep. Walls.... APPLICANT/OWNER ..... ... .. ... ..................... .. DATE . ............ ......... • • ........... I certify that as the applica t I am licensed under the provisions of the Contractors License Law and further that my License No. ............................ Environmental Status: Exempt....... Other in Classification ..,......_..............._......... Is in full force and effect: or __...._..... ................ Design Review Approval: Bldg. Site............. Sign ����........ I certify that I a exempt from the "Licensed Req.'•etl" provisions of the " '' .' '.......... Contractors License Law. (State basis of exemption., Use Zone ........_.- P.D. COOdifIOfIS ....._....._............_......._...-._................ I hereby acknowledge that I have read this application and state that the above Is Cond. Use Permit #...... Variance #...... Parking Spaces.... Load. Sp..... correct and agree to comply with all City Ordinances and State Laws regulating PprovedBY....._.._.............................. .......-......... Date ........................... building. • • I (we) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way secure against said City in consequence of the granting of this permit. nCfOaChmenf Permit......... Grant Of Easement_........_....__.... SIGry.�NATURE OF �( Curb, Gutter, Sidewalk,. Driveway: Replace Repair APPLICANT/CONTRACTO ............................................-....... DATE ............................ Sewer............ Conn. Fee $_.............. Water................ Meter $._............ NOTE: When properly validated this form consulates a Building Permit. This Agreement for Completion of Public Works Improvements .................. permit expires and becomes null and void should work not be commenced within Plans Checked By........ Date........ Approved By........ Date.................... 120 days from validation dale, or should authorized construction be suspended a abandoned for a period of 120 days after work Is commenced. APPLICATIOs • ELECTRICAL PERMIT PERMIT INSTALLATION NO. EACH FEE APPLICATION •• PLUMBING PERMIT Light Outlets....-....... Switches............ PERMIT INSTALLATION NO. EACH FEE Fixtures............ Receptacles............ Gas Sytem with up to 5 outlets ................................... $ 4,00 - - TOTALNUMBER(less than 1000 watts)......._.._._. ...$ ,50 --....---- Each additional outlet .............._... ........... .......... 1.00............... Range........ Cooking Unit........ Oven* ................. 2.00 . .............. Water System (Installation, Alt. or Repair) ................ 4.00 ............. Dryer.... Garb. Disp..... Dishwasher.... .--.... ......._. 2.00 ......_....... Water Closet.... Water Heater.... Ld. Tray.......... ........... 4.00.............. SERVICE OR TEMPORARY POWER to ... 2.o0 . .............. Lavatory.... Shower Pan.... Bathtub.... Sink.................. 3.00,............. 100 amp/$5.00, 200/$7.00, 500/$9.00 Wash. Mach..... Dishwasher.... Garb. Disp..... .............. 3.00 ............. 600/$20.00, 1200/$40.00 ..................... ............................................. Sewer .................................................-............................. 6.00. ............. MOTORS, Generators,Welders, Heaters, Lawn Sprinkler Sys. $6.00 Ea. add Sys. $2.00.................................... per HP—KW—KVA to 1/$2.00, 5/$3.50, Vacuum Breakers ............................................ . ............ 4.50'.............. 20/$6.50, 50/$10.00, 100/$12.00, Slop Sink........ Floor Sink........ Floor Drain ................ 4.00500/$15.00 ........_.__..___.............-.....__._...__..........._....... ............... Urinal.... Interceptor.... Wa[er Softener.... ..........I ............ 4.00Signs with I XFMR ....................................... ............. ... 2.00 ...............- Plumbing Piping withou!fixtures .................................. 4.00 ............. Each additional XFMR/Time Clock .. .............. ... .50 .. .............. Misc. ........................................................................................................... Annual Electrical Maintenance . ................ 25.00 ................ Permit Fee ..........................................................................$ 6.00 Other (see Ordinance Curre t) ........ .................... ................ ..... .... TOTAL PLUMBING PERMIT FEE (plus penalty if app ) $ APPLICATION FOR HEATING/COOLING PERMIT Permit Fee ......................................._..........----................. $ 6.00 PERMIT INSTALLATION NO. EACH FEE TAIL ELECTRICAL PERMIT FEE(plus penalty if app.�) $ daz Forced Air Unit...............to 100M .................................$ 6.00 ............... INSPECTION RECORD over 100M -.........-................. 10.00 ............... Comfort Cooling Unit.....to 3 ton/HP............................ 6.00 ............... Forms / Foundation............................... By:.................. Date:................ to 15 ton/HP........................... 9.50 ............... Plumbing Ground Work ......-.... ............ --.............................................. to 30 ton/HP.... ..................... 12.00 .......`...... MughElectrical ..................................... ....................................-............. to 50 ton/HP.......................... 17.00 ............... ma - Plumbing and Heating .............................................................. Space Heater........ Wall Heater ......................................6.00 ............... sulatlon / Energy................................................................................... Flues - other than above ................................................3.00 ............... GasTeat ............-...................................................................................... Vent Fan: Kitchen........ Bath ............................._..........:.3.00 ............... Temporary Power Gas / Elect............. Commercial Range Hood .............. 6.00 Final - Electrical ........................................................................................ Misc. ........................................................................................................... Final - Building/Mechanical .................................................................. Permit Fee ........................................................................$ 6.00 Final - Design Review / Landscaping ..................................................... TOTAL Htg./ Coolg. Permit Fee (plus penalty if app. ❑) $ Final — Public Works........................................................... Sheet ,2 CITY OF CUPERTINO BUILDING PEMIT Permit No: _ Address: �t Date: BUILDING PROJECT IDENTIFICATION q WORKERS'COMPENSATION DECLARATION' Applicant's Mailing Address 0 poop,FPrp K !T I hereby affirm that I have a certificate of consent to self-insure, ''ee or a certificate of Workers'Compensation Insurance,or a certified S? UFws eCR copy thereof (Ser g0(1„ b,C.�. Address of Building K Policy No. Cumpaany Certified copy is hereby furnished. Owner's name _C ICH (✓�Y B Certified copy is filed with the county building inspection Telephone No. department or county Date department. Contractor's Name Ou1pER —CORIRCTfZ Applicant , Contractor's flailing Address CERTIFICATE OF EXEMPTION FROM WORKERS' Lic. No. COMPENSATION-INSURANCE (This section need not be completed if the permit is for one 'Architect or Engineer hundred dollars (5100) or less.) - Architect's or Engineer's Address I certify that in the performance of the work for which this permit Lic. No. is issued,I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California. LICENSED CONTRACTORS DECLARATION 1� 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, you must forthwith Professions-Code,and my license is in full force and effect. comply with such provisions or this permit shall be deemed revoked. License Class Lia Number Date Contractor CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit,is,issued (Sec.3097, OWNER-BUILDER DECLARATION Civ.C.). Lenders Name I 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 t Code: Any city or county which requires a permit to construct,alter, I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county improve,demolish,or repair any structure,prior to its issuance,also ordinances and state laws relating to building construction, and requires the applicant for such permit to file a signed statement that hereby authorize representatives of this county to enter upon the he is licensed pursuant to the provisions of the Contractor's License above-mentioned property for inspection purposes. Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.3 Signarare of Applicant er Aaent Dare by any applicant for a permit subjects the applicant to a civil penalty 0not more than five hundred dollars ($.i00).): 1,as owner of the property,or my employees with wages as "OWNER-BUILDER VERIFICATION I&sole compensation,will do the work,and the structure is not 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 "An 'owner-builder' building permit has been applied for in Property who builds or improves thereon,and who does such work your name and 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 unnecessary delay building or improvement is sold within one year of completion,the in processing and issuing your budding pertnit.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,am exclusively contracting with construction of the proposed property improvement (yes or no) licensed contractors to construct the project (Sec.7044,Business and Professions Code: The Contractor's License Law does not apply to - 2 I' (have/have not) signed an application for a an owner of property who builds or improves thereon, and who building permit for the proposed work contracts for such projects with a contractor(s) licensed pursuant to a I have contracted with the following person(firm)to provide the Contractor's License Law.). the proposed construction: [:11 am exempt under See. , B.hP.C. for this Name reason Address City Datr. Z / _ Owner Phone Contractors License No. If 4. I plan to provide portions of the work, but I have hired the • yZV -- wor7followng person to coordinate,supervise,and provide the major work- Name Address City Phone Contractors License No. S. 1 will provide some of the work but I have contracted(hired) the following persons to provide the work indicated: Name Address Phone Type of Work . i• Signed: Property owner Social Security number Date: