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1091CITY OF CUPERTINO APPLICATION FOR RESIDENTIAL BUILDING PERMIT AND ' CERTIFICATE OF OCCUPANCY BUILDING INSPECTION DIVISION M11 P Plans Received By .................................................... Date ......................... REO.: Plans.... Survey ... .�rales: St c..... Energy.... Elect..... Meeh.... Plans Checked By ..........4V G��-I "Bel. 7,........ Date ............. Application Approved By .....:....l? L.....r.................. Date ..�a/.a...> . ValidatedBy.............................................................. Date ........................ Compensation Certificate Verified By ................. Date ............,............ . 2.00 MOTORS: 1 HP or less ................................................. 2.00 Greater than 1 HP not more than 5 HP ............... Permit Fee (plus penalty if applicable) ........................ $../[.1"��...�. Plan Check Fee (less deposit of $.......... Rct. #..........) Energy Plan Check Fee (Dep. of $........ Rct. #........) $................... . Strong Motion Fee .......................................................... $......'..G...... Plumbing Permit Fee ................................................ $..............:........ Electrical Permit Fee ...................................................... $....................... Mach. Htg./Coolg. Permit $............................. $ ....................... Residential Construction Tax ........................................ $ ....................... Misc. Fee........................................................................ $...........0 O.. Misc. Fee........................................................................ $............. • s3�s�.7 9 Environmental Status: Exempt ............ Other .............. :......................... Design Review Approval: Bldg ............. Site ............ Sign ............ Use Zone ............ P.D. Conditions............................................................ Cond. Use Permit #............ Variance #............ Parking Spaces............ ApprovedBy ........................................................... Date ........................... - u F • roachment Permit ........................ Grant of Easement........................ WWWeb, Gutter, Sidewalk, Driveway: Replace.......... Repair.......... r............ Conn. Fee $................ Water................ Meter $ ................ Agreement for Completion of Public Works Improvements .............:.... Plans Checked By........ Date........ Approved By........ Date .................... ' PERMIT INSTALLATION NO. EACH Light Outlets ............. Switches............ 1.00.............. Fixtures............ Receptacles............ 4.00.............. TOTAL NUMBER (less than 1000 watts) ............ $ ,50 Range........ Cooking Unit........ Oven ..... ....... ......... ..... _ 2.00 Dryer........ Garb. Disp......... Dishwasher . ..... - .... ....... . 2.00 MOTORS: 1 HP or less ................................................. 2.00 Greater than 1 HP not more than 5 HP ............... 3.50 Temporary Power Pole or Service — 100 amp ..........5.00 .... 3.50........... ." — 200 amp ......... 7.00 TimeClock ..... :.............................. .......................... ...... 1, 1.50 Misc. (see Ord. current 1 ...................................................... New Residential Occupancies Flat Rate 0-600 sq. ft. $22.00 1501-1750 $34.50 .............................. 501-750 •24.60 1751-20000 37.50 .............................. 751-1000 28.00 2001-225G 39.50 .............................. 1001-1250 28.50 2251-2500 42.00 .............................. 1261-1600 32.00 2501-2750 49.50.o ..... o .... o ...... Permit Fee...............................................$8.00 TOTAL ELECTRICAL PERMIT FEE (Plus penalty If app.❑) $ -'. t' Forme / Foundatitidw ............................ By:........ _. Plumbing Ground Work .. ......................... ............ Rough Electrical......:5..... ...................... i.................... ----vme Plumbingand.Heating Illation S Energy,._>}y....................... .................... S Test............... .........x.............. ....... .,...._............. emporary Power Gas /Elect .......... .1 ....... Final - Electrical.................1......................................., Final - Building / Mechanical .............. .................... Final - Design Review / Landscaping .................... Final -Public Works / Date: ............ i -.PERMIT NUMBER I if 0 Legal Description: Tract_fA; iC.1........ Block............ Lot ...................... DESCHIon of Work: ............ ..... ...t.- ouil......wfi..L.L........................................................... 1st Struct. Improvement on Parcel: Yes.... No... Area of Bldg ............... Separate Structure............ or Addition/Alteration to Exist. Bldg........... No. of Stories ................ Usk of Buuiilldding................. ......... ....................... Valuatio of Is 'e t: gg.�..�...,' .. ... .. TOW Owner: Ol.A. Fi ti41J.St............................ Phone 5. Contractor:... RK . ...................................City Bus. Lic. #14a5Z/.3- Contractor's Address: .......... . ddress:...................... Phone:.................... Contractor - Electrical: ....... ............ ....... lectrical:............................................................................. City Business License #.................... Phone:.................... Plumbing: ...................................................................................... City Business License #.................... Phone:.................... Heating and Cooling ................................ .------- ................. :........ City Business License #.................... Phone:.................... Architect/ppengr• ...... ............. ... Phone:................... Engineer: ....�IA:IJ1.11ppfib........ ...Phone:.!m.L11.16 Lender: .............. ........................................ .. ❑ Unknown, .. .. "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 to the workman's compensation laws of California." SIGNATURE OF APPLICANT/OWNER... ................................................ _.......... :......... CATE ........................ ......_ "I certify that as the applicant I am licensed uncle- the provialons of the Contractors License Law and further that my Licari No . ............... _._...... in Classification ........................................ Is in full force end effect: or ....... I certify that I am exempt from the "Licensed Required" provisions of the Contractors License Law. (Stale basis of exemption.) I hereby acknowledge that I have read this application and state that the above Is Correct and agree to comply with all City Ordinances and State Laws regulating 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 acture against said City in conseqUitince of the granting of this permit." SIGNATURE OF I'A,,1.,,!^^4A�nrn1�.'.� I �'Z�..Q/1 APPLICANWCONTRACTOR {.. ................ DATE118-...._.....V..S/ NOTE: When properly validated this form constitutes a Building porta. This permit expires and becomes null and void should work not.be enmmanced within 120 days from validation date, or should eulheda•d conamietlon be suspended or abandoned for a Period of 120 dare after work Is commenced. L - .. ...2 _. Gas System with up to 5 outlets .................................$4.00 .............. Each additional outlet ............................................. 1.00.............. Water System (installation, Alt. or Repair) ................. 4.00.............. Water Closet.... Water Heater.... Ld. Tray ........... ........ .. 4.00.............. Lavatory.... Shower Pan.... Bathtub.... Sink ........ ........ .. 3.00 .............. Wash. Mach..... Dishwasher.... Garb. Dlsp..... ..... ........ .. 3.00.............. Sewer............................................................................... 8.00.............. Lawn Sprinkler Sys. $5.00 Ea. add Sys.$2.00.................................. ......... 3.00.......... Vacuum Breakers ............................................ .......... .... 3.50........... Interceptor........ Water Softener ........ ................. ........ _..4.00. ........ .... Plumbing Piping without fixtures ...................................4.00.............. _......... $ 6.00 Misc. (See Ord. Current) .................................................... ,NJID— 7 PermitFee............................................................:.............$ 8.00 TOTAL PLUMBING PERMIT FEE (plus penalty if app. ❑) $ , over 100M ....................... __ . 16 .00 .. ....... Comfort Cooling Unit...... to 3 ton/HP ................. .......... 0.00.......... to 15 ton/HP................. ....... 9.50 ......... to 30 ton/HP ................ ......... 12.00 ......... to 50 ton/HP ........................ . 17.00 ......... Space Heater........ Wall Heater ................................... 6.00......... Flues - other than above ..................................... ......... 3.00......... Vent Fan: Kitchen........ Bath ............................... ......... 3.00.......... Commercial Range Hood ................................... ......... 6.00........... Misc. (See Ord. Current ........................................ ...................... ........ PermitFee............................................................. _......... $ 6.00 TOTAL Htg./ Coolg. Permit Fee (plus penalty if app. p) $ ,NJID— 7