1789 ,�y �� C1iPEaS�N�
�JUPPLEMENTA�fiI
CITY OF CUPERTINO �AkA 13
• APPLICATION FOR RESIDENTIAL BUILDING PERMIT gA� PERMIT NUMBER
AND FOR APPLICANT TO FILL IN
CERTIFICATE OF OCCUPANCY
BUILDING INSPECTION DIVISION STREET ADDRESS OF PROJECT:
........._.102Q6...English_Qak..WaX_.................__.........................
a • - • Legal Description: Tract... 6551.. Block........ Lot..19...............
Description of Work: ........ .-
....... .........•-........._................_......._......
Plans Received By..._........._...._......_..........._......._Data ......................... ...........__.............._....._....solar...Permit............_....._............... -_
REO.: Plans.... Survey.... Calcs: Struc..... Energy.... Elect..... Mach.... list Struct. Improvement on Parcel: Yes.... No... Area of Bldg.,..._..............
Plans Checked By........._........._...................._......-.Date ......................- Separate Structure............ or Addition/Alteration to Exist. Bldg
Application Approved By....................... ............. Date ..__..._...._........ No. of Stories........... .. ............. ........
..... Use of Building _
Validated BY - .. ....... ......Date .................... Valuation of Protect $.... ..... -- -...... .. ...
Compensation Certificate Verified By ... ... Date - _.............. Owner' ..... ... Phone. ....
• • • • • Contractor: .._ BAS._HOMES.,-INC....City Bus. Lic. # ..............
$ Contractor's Address: ......_.... ....... -..............._.. Phone:..............._.
Permit Fee (plus penalty if applicable) _ 24: .
Contractor - Electrical: .. ...... _ _.............. ...... ..................—.........
Plan Check Fee (less deposit of$......... Rct. #. _ $ ..............
City Business License #. .............. Phone:....................
Energy Plan Check Fee (Dep. of $.... Rct. #........) $...................... Plumbing: ................._..._._..........._..........._............................._..
Strong Motion Fee ........._.............._......._... .........$......_.a..�`�....... City Business License #....... ....._..... Phone:...............
...
Heating and Cooling ......._.........__....._............._..........._.........
Plumbing Permit Fee ......_..__................$..../.0..:.2'51..... HeatCity Business License #.........._. .........
__... Phone:........._
Electrical Permit Fee ..... ....._...__..._...._.................$........_...._.......
Mach. Htg./Coolg. Permit it $$............................. $............... Architect/Designer: ...._......_..............__._........... Phone:..-.............
....
Engineer: .... ._........_._................._............._........_..._ Phone:.........._...
wn
Residential Construction Tax .. ....._........................__..$..... Lender: .
_ ....... ... ......................_........................... Unknown
Mist. Fee ..........................__................._......_............. .
$ .. "I cert ily that in the peony person
of the work for which this permit is
MISC. Fee ........................................................................ ...................... issued I shall not employ any person in any manner so as to become subject
• $ 24.50 to the workman's compensation laws of California."
SIGNATURE OF
• • APPLICANT/OWNER ........_ ..................................._...... ......_.. DATE........................
Environmental Status: Exempt ......_.... Other... .... ... .. "I certify that as the applicant I am licensed undethe provisions of the
Design Review Approval: Bldg. — Site ._......... Sign ............ Contractors License Law and further that my Licens. No. ......_..............
Use Zone ............ P.D. Conditions ................_..... in Classification ...._...... .................. is in full force and effect: or
Cord. Use Permit #........... Variance #............ Parking Spaces...._._._ . I certify trial I am exempt from the "Licensed Required" provisions of the
Approved By. '" "' - "" """""""""Date Contractors License Law. (state basis of exemption.)
---"'"'" I he,eby ,cknowlPdgc 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
mildmg.
I (We) agree to save, indemnify and keep harmless the City of Cupertino
f1ClOBChmBnt Parmd...._..._.....-__... 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 consequence of the granting of this permit."
Sewer............ Conn. Fee $........._..... Water..... Meter $........ SIGNATURE OF
Agreement for Completion of Public Works Improvements ... APPLICANT/CONTRACTOR .___................................................ DATE ......................-.
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
APPLICATION • - ELECTRICAL PERMIT 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
Light Outlets.........._ APPLICATI• • • PLUMBINGSwitches............
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 .............
Greater than 1 HP not more than 5 HP .......I....... . 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.l.....-. 7.00 .. ............ Sewer .............___......................._.......-........................ 8.00...............
Time Clock ............._...._...._......._....._......_...._........._.- 1.50........._.... Lawn Sprinkler Sys. $5.00 Ea. add Sys. $2.00.....................
.............
Misc. (see Ord- current). ies F. .-.Rate Vacuum Breakers ........................................ . . ..............3.50..
NOW Residential Occupancies Flat Rate Interceptor........ Water Softener........ .............................4.00.
............
Plumbing Piping without fixtures ........................ ......4,00 .....-__,....
0-500 sq. ft. $22.00 1501-1750 $34.50.............................. Misc. (See Ord. Current) ....SQ�.$S..F?�Ymlt. 4.0
501-750 24.60 1751-20000 37.50.............................. '•
751-1000 26.00 2001-2250 39.50.............................. Permit Fee ....-....................... ..-.........................................$ 6.00
1001-1250 28.50 2251-2500 42.00.............................. o TOTAL PLUMBING PERMIT FEE (plus penalty if app. 0) $10.00
1251-1500 32.00 2501-2750 49.50.............................. APPLICATION • , HEATING/COOLING PERMIT
Permit Fee...............................................$6.00
TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.0) $ PERMIT INSTALLATION NC EACH FEE
Forced Air Unit............._...t0 100M ......._..
...................$ 6.00 ............
INSPECTI
ON • ' over 100M ................. ....... . 6.00...............
10.00.. ..........
.. ........... ........ ..
Forms / Foundation ..... ... .... ............. By: Comfort Cooling Unit, 3 ton/HP ... .
..,._.. ....... . Date:................
Plumbing Ground Work I.. � to 15 ton/HP..............._._..... 9.50..............
._.... .._...._............._..........
Rough Electrical .... to 30 ton/HP........................ ..12.00. ............
9 .......Hes_......_........J... ........_. ......... ............... ....._.... to 50 ton/HP.........................
rams - Plumbing and Heating .17.00.. ...........
9 9 .._...............................`............_._......__ Flues Heater Wall Heater ......._......._........... 6.00
sulation 8 Ener ..............
Energy ........................... ........._......_.... _....................._.. Flues - other than above .._..._......._......._....-....
Gas Test .........................._....._ ._... - ................. ' . .......I. 3.00..............
Vent Fan: Kitchen........ Bath _........ .......... ................. 3.00...............
Temporary Power Gas / Elect. ....... Commercial Range Hood 6.00
Final - Electrical ...... ....................................................`._........._............. Misc. See Ord. Current............_......._.........._ ... ...............
Final - Building / Mechanical .................... _....... .......`........_............._ ( �.................._._ ............
Final - Design Review / Landscaping . . Permit Fee ................... . .. ........................._......— $ 6.00
- ---- TOTAL........................................................... Htg / Coolg Permit Fee (Plus penalty 'y
app. O) $Final—Public Works