1954 • CITY. Of, CUPUT1,0 •
CITY OF CUPERTINO 131311
APPLICATION FOR RESIDENTIAL BUILDING PERMIT ISA 3 PERMIT NUMBERAND
• FILL IN
CERTIFICATE OF OCCUPANCY • APPLICANTa
BUILDING INSPECTION DIVISION T J DRESS FPROJECT:
.[...H.1S"/7NR -M............................."........."....
..:............
DEPARTMENT USE ONLY Legal Description: Tract........................ Block............ Lot......................
Description of Work: ................................-...-........................................
Plans Received By....................................................Date ......................... .................Sot,, ....W&. ......HCA21Ltc....._...._................
...:..._."
REQ.: Pians.... Survey.... Coles: 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...........
..........Date .s.2 "..S t i - Use of Building .....S.�l?-...............................
Approved B ......... No. o Stories..._....._...
ApplicationPP Y ..... ...."" -. g
Validated By............................................................Date ---.................... Valuation of Pro act $......J.ooA............_......................_.....................
Compensation Certificate Verified By -.... -"--.. Date ......................... Owner: .. N.1A/.2-A!v.l..._................................ Phone:....................
Contractor: .. (yow_.$'o c.�nc.... .......City Bus. Lic. a
orywyan. • •• • $ 3f Contractor's Address: A-3.6 0..3....._f1d4.fF?.'ee..... Phone:.3.77:n.3411
Permit Fee (plus penalty if applicable) ......."......".........$a.. _.............
Contractor - Electrical: ........................ ............--..................
Plan Check Fee (less deposit of$.......... Rct. #.... _...)$......a...d'-O City Business License •......... Phone:Phone:....................
"' Plumbing:
Energy Plan Check Fee (Dep. of $........ Rct. #........)$.........".... ......................................................................................
Strong Motion Fee ....................................................._ ♦ Phone:....................
...$........... .. City Business License ...-................
" Heating and Cooling .........._ _...._................................
.....-"..................".... $.
Plumbing Permit Fee ..... _._....
_ . ............... ..�Cy.. City Business License a.__..-............ Phone:....................
Electrical Permit Fee ......._.....-......-..............._.............$.... ... Architect/Designer: .. ................................-_..._....... Phone:....................
Mach. Htg./Coolg. Permit $............................. $------................. Engineer: ......_......................... Phone:....................
Residential Construction Tax ..................................... ..$...................--- _ ......_
.. _............. ....... ..................___.._...._........... Unknown
Mise. Fee ..........._...._......._._..-.........................__...--$. ....-.............." LOndeC _ ❑
I certify that in the performance of the work for which this permit is
Misc. F80 ........................................................................$....................... issued I shall not employ any parson in any manner so as to become subtest
• _ $ <e 0,00 to the workman's compensation laws of California."
• SIGNATURE OF
• • APPLICANT/OWNER ......................................... .. DATE.-.....................
Environmental Status: Exempt ............ Other............... ...................... "'I terrify that as the applicant I am licensed unde the pro Islons of the
Design Review Approval: Bldg. ............ Site ....... Sign ....._.... Contractors License Law and further that my Licens. No. .. .1x.9.9.9.....
Use Zone P.D. Conditions in Classification ....l3.....C..4.!1............ is in full force and effect: or
......rmi ......................arks...-....... ccs............
Coed. Use Permit �".._........ Variance a............ Parking Spaces............ - certify that I am exempt fromStat the "Licensed Required" provisions of the
Approved B Date ._.... Contractors License Law.
(State basic of exemption)
PP Y""-"-"-"""""- - """""-""""""" "" - -""""" 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, Indemnity and keep harmless the City o1 Cupertino
41 ncroachment Permit.....".""""".."......... Grant Of Easement...................... against liabilities, judgments, costs and expenses which may in any way
Urb, Gutter, Sidewalk, Driveway: Replace........." Repair.......... acture against said City In uance'of the granting of this permit."
Sewer............ Conn. Fee ....... Water................ Meter $....--........ SIGNATURE of ) p y
Agreement for Completion of Public Works Improvements .......--....... APPLICANT/CONTRACTOR .. /... e n'......._._.._......... DATE .J..'3..tY..L.
Plans Checked By........ Date........ Approved By........ Date.................... NOTE: When properly validated his.form consmute• a Building Permit. This
permit expires and becomes null and void should work not be commenced within
APPLICATION FOR 120 days from validation dere, or should authorized construction be suspended or
reassesses, I 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 ""a 14f v Water Closet.... Water Heater../Ld. Tray..................... 4.00. .fGU.L..
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. atltl Sys. $2.00........_........ .
Misc fees Ortl current 1 . ............ ................. .......... Vacuum Breakers ......................................-..... ..............3.50..............
New Realdential Occupancies Flet Rate Interceptor........ Water Softener........ ......."......... ...........4.00. ....
Plumbing Piping without fixtures ...................................4.0O.
. .f......
0-500 eq. ft. $22.00 1501-1750 $34.50.............................. Misc. (See Ord. Current) ....................................................
501-750 24.60 1751-20000 37.60.............................. Permit Fee ...............................".........................."...............$6.00
751-1000 20.00 2001-226C 39.50.............................. TOTAL PLUMBING PERMIT FEE (plus penalty if app. 1_1) $ UU
1001-1250 28.60 2251-2500 42.00..............................
1251-1500 32.00 2501-2750 49.50.............................. APPLICATION FORHEATING/COOLING IIERMif
PermitFee.......:.......................................$8.00
TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.0) $%l-d PERMIT INSTALLATION NO. EACH FEE
Forced Air Unit..................to 100M ..............................$8.00...............
— INSPECTION RECORD over 100M ........................ . 10.00.. ...........
Comfort Cooling Unit......to 3 ton/HP .........:....... .......... 6.00... ...........
Forms / Found et Ion ..._..____...._...... . By:........ ....... . Date:-.............. to 15 ton/HP......................... 9.50.............
Plumbing Ground Work .......-....... .._...._................. to 30 ton/HP........................ ..12.00. .........._
Rough Electrical ......-._....._................. ..................... .. ........ to 50 ton/HP................ ...........17.00..............
time - Plumbing and Heating . .......I .. .. .. ............ Space Heater........ Wall Heater ......._.................. "".....� 6.00,.............
�i,
ulatlon 8 Energy.....SC.�.A. ........ ....yJ.p y..'_Z.y'S'� Flues - other than above ............. 3.00..........."-
esTeat .................__.............._..... .. .................. ........_....__._...... Vent Fan: Kitchen........ Bath .............................".._..._.. 3.00...............
Temporary Power Gas / Elect, . ........... .........I.... Commercial Range Hood ............ ...... 8.00...............
Final - Electrical _..._............................................... ........ Misc. (See Ord. Current...................._..._......._........... ..,.......
.................
Final - Building/ Mechanical ....................................... .......................... Permit Fee .............................-........- ............................ $ 6.00
Final - Design Review / Landscaping . ...... TOTAL Htg./ Coolg. Permit Fee (plus penalty i1 app. (]) $
Final-Publlc Works ...........................................................