1754 CITY OF CUPERTINO Clic OF CUPEn71NO
APPLICATION FOR RESIDENTIAL BUILDING PERMITIJAN 1951 PERMIT NUMBER / 7$
AND FOR TO FILL IN
CERTIFICATE OF OCCUPANCY
BUILDING INSPECTION DIVISION _ T ADD SS OF PROJECT:
89_...rC.!(.[N(E.�....(�.9� .. _.._..............:.............
s • • • • Legal Description: Tract........................ Block............ Lot......................
Description of Work: ..........
Plans Received By.............-....................................,Date .........................
REO.: Plans.... Survey.... Calcs: Struc..... Energy.... Elect..... Mach.... tat Struct, Improvement on Parcel:Yes.... No. . Area of Bldg...............
Plana Checked By.................................... Date ... . .. Separate Structure............ or Addition/Alteration to Exist. Bldg...........
Application Approved By.........._. .x_r<....' Date No. of Stories.........._.._ Us of Buapg ............
Validated By_........... ....... Date .................._.... Valuation Af Project: $......7.:SO_ ....___..-........................._...._............
Compensation Certificate Verified By ................. Date ........................ Owner: .4fCCA1.4g9S .____........ .......................... Phone:...............:...
Contractor: A+Af_L•f.�lt77V&...._..._.City Bus. Lic. #Cle..... ,
" • $ Contractor's Address: LG.2Z.d1•../2 T._......_ Phone 2.270.2.9Z.
Permit Fee (plus penalty if applicable) ........................$.._.................. Contractor - Electrical: ......................._.._.......__..:....... ..........................
Plan Check Fee (less deposit of$......._ Rct, #...:.....)$................._.... City Business License #_...._............ Phone:....................
Energy Plan Check Fee (Dep. of $........ Rot. #........)$_...... Plumbing: .......-.........................................................................
.....
Strong Motion Fee .._................._ .............................$...................... City Business License #.......... Phone:_._...............
Plumbing Permit Fee $, Heating and Cooling .1YL .._........_................_......
.............
.........._............_......._.......__.. ._....__........... __ C Z
Electrical Permit Fee ................ ,.,_.__$„_._,___._ City Business license # � .... Phone;��g.._7....
.__._....._..._..._._. . Architect/
Designer: ....__ ...___.......
one ................
Mach. Htg./Cool9. Permit $............................. $ ..
Engineer:
Residential Construction Tax . - - - - $ ............ __.........._ .. .. _... Phone: .... . .
------ Lender ❑
... Unknown
Mise. Fee ..................._._......................................._.......$.........._.._....._ 'I certify that in the performance of the work for which this permit Is
Mise. Fee ........................... $....................... issued I shall not employ any person in any manner so as to become subject
]tell $ to the workman's compensation laws of California.”
SIGNATURE OF
• e APPLICANT/OWNER ..._..._..........._..__...................._.._............. DATE........................
Environmental Status: Exempt............ Other............._........................ l certify that as the applicant I am licensed unde the pr v�. qq;g o the
Design Review Approval: Bldg. ._._....-. Site ...:........ Sign ............ Contractors License Law and further that my Users, No. .3f,]YEx..-...
Use Zone ............ P.D. Conditions .........____.... ...._..............._........... in Classification .......42 Q........._... is in full force and effect:. or
Cond. Use Permit #._......... Variance #............ Parking Spaces............ I certify niat I am exempt from the "Licensed Required" provisions of the
Approved By. Date Contractors License Law. (State basis of exemption.)
""""""""""""""""""""""""""""" """""""""""""' I hereby acknowledge that I have read this application and state that the above is
. s correct and agree to comply with all City Ordinances and State Laws regulating
build,nq.
I (We) agree to save, indemnify and keep harmless the City of Cupertino
croachment Permit._......_-........... Grant of Easement........................ against liabilities, judgments, costs and expenses which may in any way
'arb, Gutter, Sidewalk, Driveway: Replace._....... Repair.......... occurs against said City in consequence of the granting of this permit.''
Sewer............ Conn. Fee $................ Water................ Meter $................ SIGNATURE OF w L� Q ��,/ UU
Agreement for Completion Of Public Works Improvements .................. APPLICANT/CONTRACTOR (JG4.¢br•....1..�.':".✓... DATE Isl'.3140
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
• • 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 ,
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, All. or Repair) ................. 4.00...............
MOTORS: 1 HP or less ...... ... _.,._._............._._. ,....... . 2.00 - - Water Closet.... Water Heater.... Ld. Tray..................... 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)...................................................... Vacuum Breakers ..............3.50..
New Residential Occupancies Flat Rate Interceptor........ Water Softener........ .............................4.00. ............
0-500 s ft. $22.00 1501-1750 $34.50.............................. Plumbing Piping without fixtures ...............................4.00...............
q• ....
Misc. (See Ord. Current) ......................................"••
501-750 24.60 1751-20000 37.60.............................. 0
751-1000 26.00 2001-2250 39.50.............................. Permit Fee .............. IT ...................................................$6.00
....
1001-1250 28.60 2251-2500 42.00.............................. TOTAL PLUMBING PERMIT FEE (plus penalty if app. 1_1) _
1261-1500 32.00 2601-2750 49.50..............................
APPLICATION FOR HEATINGICOOLING PERMIr
Permit Fee...............................................$8.00
TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.p) $ PERMIT INSTALLATION NO. EACH FEE
Forced Air Unit..............._to 100M ..............................$ 6.00�,� ..—.
mocnE • • ' • 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. ...........
,.Rough Electrical . ... {-._. _. . . - . . .. to 50 tori................. ..... 17.00.. ...........
Oams - Plumbing and Heating �. ... .. Space Heater........ Well Heater .._.. .... 1 6.00
aulation & Energy . . ... ..-_. .........................-.. . Flues - other than above ... ........ ...{ 3.00.. . ..
Gas Test __...... ..._. .... .I. . - - -.... Vent Fan: Kitchen . Bath _ ` 3.00 ...
Temporary Power Gas / Elect _. . . .. .E. 6.00
Final - Electrical . --" Commercial Range Hood - .. . ... .....
-- - � Misc. (See Ord. Current... . - _.
Final - Building / Mechanical .... .. ' -. .. .. • Permit Fee .... - $ 6.00
Final - Design Review / Landscaping _.. _. ........ TOTAL Htg./ Coolg. Permit Fee (plus penalty it app. p) $
Final-Public Works ...........................................................