1354 _4
CITY OF CUPERTINO �
PPLICATION FOR COMMERCIAL BUILDING PERMIT
AND PERMIT NUMBER 3S
CERTIFICATE OF OCCUPANCY FOR APPLICANT , FILL IN
ION pjI STREET ADDRESS OF�¢PROJECT:
Plans Received B 94!i
.... .. .s... .. ........ .... ....... ............................".........P.
By....................................... Date ......."."............... Legal Description: Tract............ .......... Block............ Lot....................-.
REO.: Plans.... Survey.... Calcs: Struc... Energy..-. Elect..... Mech.-"- Description of work: ., zG, . Lot
Plans Checked By.................._ .. Improvement Bldg ApplicationBy Date ... .-/..O_-_w 9...............
Validated By.......................................................... .. Separate Structure .._....
.... . or Addition/Alteration to Exist. Bldg.-.—..
Date ......................... No. of Stories...............- Use of Buildin BL
Compensation Certificate Verified BY........_.......... Date .... .......
9 R �. """"...L""`..'...ddN
"'/j�f?
Valuation of Project: $.............................................
........ ....... ..
, , . . , GIIIIIIOwner: . ... .... Phone:
:...... ..........
.
..............
Permit Fee (plus penalty if applicable) ........................$....................... Contractor: _..._..... ........................... City Bus. Lia *.................._........._.
Plan Check Fee (less deposit of $.......... Rct. #""........)$.........."............ Address: ..... .......................... ......................... Phone:..................-.
Energy Plan Check Fee' (Dep.Gf;$.,_... Rct. #........ $..._.................. Contractor - Electrical: ..._.._............"".............................................
.........
Strong Motion Fee .............................�.'..��.?^T��,. $ City Business License *.................... Phoone:....................
v0....... Plumbing:Plumbing Permit Fee ........ . .$..... ................ 9: ..._......................._....._............................
._........_........
Cit
Electrical Permit Fee ....-_............l.... w $",fAd. ..9 Y Business License *......._........... Phone.....................
,ti.. ... ... ..... Heating
Mach. Hlg./Coolg. Permit ...................� - 6�........ . and Cooling ....................._.._"......_................_............
$ ............$................._..... City Business License *.................... Phone:....................
Construction Tax...............:......f....
.................$................._..._ Architect/Desi Designer:
Sewer Conn. Fee ........_..._ Water,CQ nn. F 9 ................_.........._........."_........ Phone:....................
$.................."....
"""""-"""" Engineer:
Landscape Fee .............._... Street Tree Fee ............$..................... ........_._...................__._......._................... Phone:.........-.
Unknown
Misc. Fee ... Lender: .cert.....that............perf..............................k for
which
th........rmit....
"'""""""",0 is certify s that In the y any person
of the work for which thio e permit It
............
XNNNU
° ' ' ' r $ I- issued I shell not employ any person In any manner ep as to become subject
Type Const......... Group, to the workmen's compensation laws of Ca]iforniI
...._. DIV.._..... DCC. Load.._.... NO. E%ItS......-. SIGNATURE OF
Floor Loads: 1st_., 2nd.... Other.... Sprinklered.... Area Sep. Walls.... APPLICANT/OWNER
..............
^ • 1 certify that as rho applicant I am licensed under the provisions of the
............
Contractors License Law and further that my License No.L.'/.q.....LZC3:!
Environmental Status: Exempt............ Other.,___-,..._...._................ in Classification ......_......_..............._....... is In full force and enact: or
Design Review Approval: Bldg. Site Sign "" "". certify that am exempt from the "Licensed Reg,'•ed" provisions of the
............ .......""...
Use Zone P.D. Conditions Contractors License Law. (State basis of exemption.,
.....................................
--... I hereby acknowledge that I have read this application and state that the above le
Cond. Use Permit ........ Variance *...... Parking Spaces.... Load. S
Approved By p..... correct and agree to comply with all City Ordinances and State Laws regulating
............._.......................... . .... 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
ICroachment Permit........... "" Grant of Easement.,..........._......... secure against said City in consequence of the granting of this permit.Curb, Gutter, Sidewalk,, Driveway: SIGNATURE OF
Replace Repair APPLICANT/CONTRACTOR ..
Sewer............ Conn. Fee $................ Water......."".....". Meter $................ ved this.t a DATE ....-.......................nuthis
NOTE: When properly vets null this loon should
Cork o Be cnq enal Thin
Agreement for Completion of Public Works Improvements .................. permit expires and becomes null and vole •nould work not be wmmanced within
Plans Checked By........ Date....._.. Approved By........ Date.................... 120 day from validation dote, or should authorized construction be suspended or
abandoned for a period of 120 days after work Is commenced.
PERMIT INSTALLATION NO. EACH FEE °
Light Outlets............ Switches............ PERMIT INSTALLLLLLLLLATION NO. EACH 7-�_
Fixtures............ Receptacles............ Gas Sytem with up to 5 outlets ...........................
TOTALNUMBER(lessthan 1000watts).._ . -- $4.00 .
"........... $ .50 Each additional outlet ............. 1.00
Range.. Cooking Unit....w Oven............ ............. ... 2.00 ..-............ Water System (Installation, Alt. or Repair) ............... 4.00
Dryer.... Garb. Dis _ .
p..... Dishwasher... ........ ................. 2.00 Water Closet.... Water Heater.... Ld. Tray.......... .......... 4.00.
S� TEMPORARY POWER to 2.00 ."
- "" """""""" """ .............. Lavatory.... Shower Pan.... Bathtub.... Sink.................. 3.00, "100 em $5,012 20$40.0 0, 500/$9.00Wash. Mach..... Dishwasher.... Garb. Diep..... .............. 3.00 1,
.00, 1200/$40.00 ............... . (.."Q 8.00.
Sewer ............_....... -... . ........................ .
MOTORS, Generators,Welders, Heaters, "" "" 0�"""��. add ..� � -..------
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/$8.50, 50/$10,00, 100/$12.00, Slop Sink........ Floor Sink........ Floor Drain ................ 4.00.....___...._.
500/$15.00 .........__"........__.._..................._......... Urinal...-...Int Interceptor tor.... Water Softener........................... 4.00 ............. '
Signs with I XFMR ....................... .......... .............._ 2,00 """"""-....... Plumbing Pim without fixtures ........... 4.00
Each additional XFMR/Time Clock .. .._.......... ... .50 .. .............. Mise. 1
Annual Electrical Maintenance ............._. 25.00 .. ......_...... Permit Fee .............................."..........................................._.......
..."....................................................."".......-.......$ 8.00
Other (see Ordinance Current) .................. .............................. .............. TOTAL PLUMBING PERMIT FEE (plus penalty if app. ❑) $
..............._.._.............................._.._................ ..........................................-_ .., . . . . -
Permit Fee ................................................... .. $ 6.00 Forced Air U PERMIT INSTALLATION
" NO. EACH FEE 17
... ..........
TOTAL ELECTRICAL PERMIT FEE (plus penalty if app.0) $
Unit...............to 100M ........................ ......... $ 6.00 ...............
over 100M ............................ 10.00 ...............
Comfort Cooling Unit-----to 3 ton/HP................. ........... 6.00 .......
. ........ =
Forms / Foundation..... ............. BY:...._..""...... ........"......
. Date: .
Plumbing Ground Work ......................... ..............."......... to 15 ton/HP........................... 0.50 ...._--.......III 1
" ugh Electrical .................:................... ........................ ..............".....-......
to 30 ton/HP......................... 12.001...............
.me - Plumbingand Heating to 50 ton/HP.......................... 17.00 ...............
9 ........... ................................................... Space Heater........ Wall Heater .......................... ............6.00 ......-.......
'u lotion / Energy................._-........... .... -
................................................ Flues - other than above ..............................--.. ..3.00 .
;es Test ........... . ..............
"......................"......ect.......................-.......---.............................. Vent Fan: Kitchen........ Bath .............."........................- __
Temporary Power Gas / Elect..................................... Commercial Range Hood 6.00
--........-_.-...._..... g
Final - Electrical ..._............................... ..................-............-.......-...-. .-..........-..
.................................................... Misc.
Final - Building/ Mechanical .................................................................. --..._.....-.......................................
....
..........-..........-.. ......................-....
Final - Design Review / Lands'
In Permit Fee ........................................................................$ 6.00
p g """"" ..---.....--....---- TOTAL Htg./ Coolg. Permit Fee (plus penalty if app• O) $
Final — Public Works...........................................................
Y
Sheet 2 1
;• CITY OF CUPERTINO BUILDING PMnT
Permit No:
Address: SY � ) 2 �
Date:_ C/ — Jn_ 9=6
BUILDING PROJECT IDENTIFICATION WORKERS'COMPENSATION DECLARATION
Applicants Mailing Address 7/7- ' E ,t_FY',EL YA/ flus 1 hereby affirm that 1 have a certificate c.
_Su
A/A/V!/ LI'£ 'consent to sell-insure,
or a certificate of Workers'Compensation Insurance,or a certified
Address of Building - L4 oi�'Aq£E .S T.EI�f-/VS CR, copy thereof (Sec 800, �b.C.'t.
Policy No. company
B Certified copy is herey furnished.
Owner's name E➢✓QL/C /i,w/ /�pnl T,eg Certified copy is filed with the counh building inspection
Telephone No. department or counh' department.
Contractor'sactar's Name Cu?6"fC "Tir✓O ELcaT Date Applicant
Contractor's %failing AddressEv.E'ZTy" CERTIFICATE OF EXEMPTION FROM WORKERS'
S✓A/A/V+lR t-,E COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
Architect or Engineer hundred dollars ($100) or less.)
Architect's or Engineer's Address I certify that in the performance of the work for which this permit
Lie. No. is issued,lshall not employ anyperson in any mannerso 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 pro%'isions 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 Cade, t m license is in full forte and effect. comply with such provisions or this permit shall be deemed revoked.
License Class Lie. Number /74GG 3
Date Contractor r 7-1 n/U CONSTRUCTION LENDING AGENCY
�rR«
1 hereby affirm that there is a construction lending agencv for the
performance of the work for which this permit.is issued (Sec.3097,
OWNER-BUILDER DECLARATION Cw.C.).
Lenders Name
1 herehv affirm that 1 am exempt from the Contractor's License Lender's Address
Law for the following reason (Sec.7031.5,Business and Professions
Code: Arte 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
?iprove,demolish,or ropair any structure,prior to its issuance,also ordinances and state laws relating to building construction, and
equirrs 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
Law(Chapter 9(commencing with Section 7000)of Division 3 of the above-mentioned property for inspection purposes.
Business and Professions Code) ar that he is exempt therefrom and
the basis for the alleged esem pion. Any violation of Section 703 1.3 Stgnnure of Applicant or Agent poo
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (S500).):
1,as owner of the property,or my employees with wages as "OWNER-BUILDER VERIFICATION
their sale compensation, will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions "Attention Property Owner.
Cade: 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 svho 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(or 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 building permit.No building permit
owner-builder will have the burden of proving that he did not build will be issued until this verification is received.
orimprove 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,Ausiness and
Professions Code: The Contractor's License Law does not apply to 2 1 (have/have not) signed an application for a
an owner of property wvho builds or improves thereon, and who building permit for the proposed work
contracts for such projects with a contractor(s) licensed pursuant to a 1 hove contracted with the following Tvrson(firm) to provide
the Contractor's License Law.). the proposed construction:
❑ 1 am exempt under Sec. , B.h P.C. for this Name
reawon Address City
Dote Owner Phone Contractors License No.
4. 1 plan to provide portions of the work, but 1 have hired the
following person to coordinate,supervise, and provide the major
work.
Name
AddressCity
Phone Contractors License No.
5. 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:
Properly owner
Social Security number
Date: