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1423 j _CITY OF CUPERTINO r ' APPLICATION FOR RESIDENTIAL BUILDING PERMIT PERMIT NUMBER 3 • AN; FOR APPLICANT TO FILL IN CERTIFICATE OF OCCUPANCY BUILDING INSPECTION DIVISION STRB J DDRE S OF Pg OJECT: n LoSd6_._. U a4 ... ... ...................................... DEPARTMENT • Legal Description: Tr ................ t.... Block............ Lot.... ............. . escri tion f Work: „ .... '�... Plans Received By................................................_..Date ....-----_............ if ..t 10 .XIa.1'Yt.�Ot sh..... h.... ...... ... REO.: Plans.... Survey.... Calcs: Strut..... Energy.... Elect..... Mach.... 1st'Sjrud( Plans Checked By........................ .. Date ....... . . Separate Structurli............ or Addition/Alter tion•to Exist. Bldg........... Application Approved By.......... _......Date . -.. No. of Stories......1..._... Useo u ............' Validated By............................................................Data ....... . .. Valuation of Project: V. ................................................... d ..... Compensation Certificate Verified By ..,./Y..GZ... Date .....f?"... ... Owner: ....Fr..l..l.... . . .. ... .. ............... Phona,aJ15Q1 1R�. Contractor: .�C_6iy Bus. Lic. • • • • • $ Contractor's Ad ress: .Ia7S..Lf V NI4&Alj,C., Phone:.. . � Contractor - Electrical: .. ................................. _.................................Permit Fee (plus penalty if applicable) ...... ......._...... Plan Check Fee (less deposit of$.......... Rct. #..........)$.................... City Business License +Y......_...._....-. Phone:.................... Energy Plan Check Fee (Dep. of $........ Rct. #........) $....................... Plumbing: .._...._..._...._................._..........._........................._...... C -. City Business License e_..„.._„._-....... Phone:.................... Strong Motion Fee .............................r.f...GL._::,:;,;;f..".$..........« Heating and Cooling Plumbing Permit Fee ..........................................e%................... Electrical Permit Fee .......................'•" a -o... $..............- ...... City Business License ........._........... Phone:.................... G......ti......Tar... Architect:Designer: _... ... ...._....._................._..... Phone:.................... Mach. H[g./Coolg. Permit $......... ............ $....................... Engineer: _..._...._......_............_._.._................._...... Phone:................... Residential Construction Tax ....................._...._..........$.............._....... - Unknown Misc. Fee ....._..............._....._......_..::?......�.....,r.....:,....$ Lender: .. . _.........._..._. ... ...................... ....... .... �• '� .. certify that In the performance of the work for which this permit Is SIGNAT c Misc. Fee ........................................................................$.................. issued I shall not empio y person in an manner so as to becomesubject y a Y nn . , , ; to the workman's come Ion la s of Calif r • & ( p URE OF ///JJJ • • X�1� ANT/OWNER . t ..... ..... ..... DATE.9 Environmental Status: Exempt Other ..............o........ A�PP�-- 'i r.enil that me a icam I m licensed nde the ro yy,�ge P ( y p . .7..V... Design Review Approval: Bldg. ............ Site ............ Sign ............ Connectors License L w riher roar my Livens. No. ... Use Zone P.D. Conditions in Classification ..._.... .: ........... is In full force and effect: or Cond. Use Permit Y/............ Variance is............ Parking Spaces............ I certify that I am exempt from the "Licensed Required” provisions of the Approved B Contractors License Law. (Stale basis of exemption.) pp y..........................._........._.................. Date ..........................- I hereby acknowledge that I have read this application and state that the above is _ wrrect 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 croachment Permit............ ..... Grant of Easement...... ................. against liabilities, judgments, costs a expanses which m y in any way rb, Gutter, Sidewalk, Driveway: Replace.......... Repair......... acture against said City In conse a of the gra tg his permit” Sewer............ Conn. Fee $................ Water....._......... Meter $................ SIGNATURE OF ,(L„t 9 Agreement for Completion of Public Works Improvements .._.............. APPLICANT/CONTRACTOR yy'v� .... - ATE _OS.f. PIBOS Checked By........ Date........ Approved By........ Date.................... NOTE: when properly validated Ihb 1 m e stltute s uildinp Psrmll. Thb permit expires and becomes null and void should work not.be commenced within • sU4.1111111 170 days from validation date, or should authorized constnlction be suspended or • abandoned for a period of 170 days after work is commenced. PERMIT INSTALLATION NO. EACH FEE light Outlets............ Switches............ APPLICATION , PLUMBING PERMIT 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........... 4.00 ............. 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.............. New 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.............................. Misc. (See Ord. Current) .......... .......................................... 501-750 24.50 1751-20000 37.50.............................. Permit Fee ....._.................................... 751-1000 26.00 2001-2260 39.60.............................. ........................$8.00 1001-1250 28.50 2251-2500 42.00.............................. TOTAL PLUMBING PERMIT FEEEE (plus penalty if eDP•Q) t 1251-1600 32.00 2501-2750 49.50.............................. APPLICATION PermitFee...............................................$6.00 TOTAL ELECTRICAL PERMIT FEE (Plus penalty If app.p) $ PERMIT INSTALLATION NO. EACH FEE Forced Air Unit..................to 100M ..............................$6.00............... INSPECTION • • . over 100M........................ . 10.00.. ........... Comfort Cooling Unit......to 3 ton/HP ........................... 6.00... ........... Forms / Foundation ............................_I By:........ ....... . Date:........._..... to 15 ton/HP..._.................... 9.50.............. Plumbing Ground Work . ........_...__....1..... ...........__. ........_..__........... to 30 ton/HP......................... .. 12.00..:........... Rough Electrical .....-......_.........-_._...... f ......_... ._..._. .._....................... to 50Ion/HP................. ..........17.00.... me - Plumbing and Heating .......... ........._...._..._., .._._.................... Space Heater........ Wall Heater ...................................1 6.00.. _._...... ulation & Energy__........_...._..._..... ...._............................................. Flues - Other than above ......................................_....1.. 3.00.............. Was Test ......................_........... ...... _ . ..._.................'............._...._...._ Vent Fan: Kitchen........ Bath ....................._........ ........ .. 3.00............... Temporary Power Gas / Elect. . ....... ....._......................._... ....... 6.00............... - -- ---- -- - - --- Commercial Range Hood Final - Electrical ..................._......_.........._..............._... ........................._ Misc. (See Ord. Current........_..............._....._..._......... ..... Final ....._..... Final - Building/ Mechanical ............................._....... ... ....................... Permit Fee ........ ........... $ 6.00 Final - Design Review / Landscaping ....... . ........................_............... . TOTAL Htg./ Coolg. Permit Fee (plus penalty if app. O) $ Final- Public Works ........................................................... ieet 2 t � / CITY OF CUPERTINO BUILDING PEMIT ~ Permit No: / 176 2.3 Address: /6 3 2-4 CLy Tf�c;"�ri� • Date: BUILDING PROJECT IDENTIFICATION WORKERS'COU PENSATION DECLARATION Applicant's Uailin PP ' g Address iQ 0 3' 1 hereby affirm that I have a certificate of Insurance, to self-insure, t/ or a certificate of Workers'Compensation insurance,or a certified "� p� �' copy there Utz :ah.C.'i. Address of Building .,pclLy,pC,Q/1y/ Policy No.�Cumpany Cc,_ Certified copy is hereby furnished. Owner's name. Certified copy is filed with ih ounry• buildm nspect' Telephone Ni — - p �ngntyr county• de m Date r.,/'1-710 Applicant Contractor's Name Contractor's )tailing Address £ CERTIFICATE OF EXEMPT ON FAM WORE •R fl tIOV-3 COMPENSATION INSURANCE Lic. No. (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 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 syy tic n,5�is in full force and effect. c mply with such provisions or this permit shall be deemed revoked. License Cl a - l '• "f Lic. Number Date " n 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, gJ OWNER-BUILDER-BUILDER DECLARATIONCiy.C.).Lender's Name Lender's Address - 1 hereby affirm that I am exempt from the Contractor's License • Law for the following reason (Sec.7031.5,Business and Professions 1 certify that I have read this application and state that the above Code: Any city or county which requires a permit to construct,alter, information is correct. 1 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 Signature of AppLicant or Agent Date the basis for the alleged exemption. Any violation of Section 7031.5 - - by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (000).): E] 1,as owner of the property,or my employees with wages as "OWNER-BUILDER VERIFICATION their sole compensation,will do the work,and the structure is not Property"Attentrt intended or offered for sale (See. 7044, Business and Professions Pe Y Owrer: 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 nadie 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 ini ended 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 yourbuilding permit No building permit owner-builder will have the burden of proving that he did not build wi().be Issued until this verification is received. or improve for the purpose of sale.). I. I Personally plan to provide the major labor and materials for ❑ I,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 2 [. (have/have not) signed an application for a Professions Code: The Contractor's License Law does not apply to - g PP an owner of property who builds or improves thereon, and who building permit for the proposed work contracts far such projects with a contractor(s) licensed pursuant tothe proposed construction:3 l havecontracted with the following person(firm) toprovide ' the Contractor's License law.). Name ❑ 1 am exempt under Sec. , B.&P.C. for this mnAddress City- Phone Contractors License No. Dalt Owner 4. 1 plan to provide portions of the work, but I have hired the following person to coordinate,supervise,and provide the major work: Name Address City Phone Contraclon 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 Signed: Property owner Social Security number Date: