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1237 CITY OF CUPERTINO APPLICATION FOR RESIDENTIAL BUILDING PERMIT PERMIT NUMBER /d 3 AND • , APPLICANT„ CERTIFICATE OF OCCUPANCY BUILDING INSPECTION DIVISIONSTRfOpDRESS `F EL - • • • • Legal Description: Tract.....(... Block-..__... Lot...................... _r.�''-fOQj1.......(.�Q6.iS�2/.IG Q-........................ Piens Received By...................... ...........Date Description of Work: ...._...ruc..._._................t*on._....cel:.Yes....................__........._. .. ._....... REO.: Plans.... Survey.... Cates: Strut..... Energy.... Elect..... Mach.... 1st Strutt. Improvement on Parcel: Yes.... No... Area of Bldg*'.*,..**.,. ........ Plans Checked By............................... ...__......_...Date ._. .. ....... Separate Structure......._... or Addition/Alteration to Exist. Bldg........... Application Approved By............ ...G.,....._..........Date .. rf. No. of Stories................ Use of Building .........._...... _._. Validated B {.ljf....... _...................... By................................................................Date ..................._... Valuation of Project: $..... IS-dO. ................I........... . ......... . .. Owner: H^.6,...FIO 1_ly1({. Phone. Compensation Certificate Verified By ..... ... Date ............_._..,... Contractor: ........_........._......_....._...................City Bus. Lic. # .............. • • • • • $ Contractor's Address: . ............... ............................ Phone:.................... Permit Fee (plus penalty if applicable) .ria__ Contractor - Electrical: .......____ ......... ._........._.._..__ .......................... Plan Check Fee (less deposit of$......_.. Rct. #..........)$ ............. City Business License #..........._....... Phone:. .................. Energy Plan Check Fee (Dep. of $...-.... Rct. #........)$. Plumbing: ....................... ........__.. Strong Motion Fee ..........................................................$_....._ Z7 City Business License a.................... Phone:.................... --- --------- Heating and Cooling Plumbing Permit Fee ._.............._._..._....................$_....._..._......... g 9 ........................._............._........................ Electrical Permit Fee ................ - $__,_. City Business License #.................... Phone:.................... G:. 1..�C"@i1'G:Ci........ _._............ Architect/Designer; .... ............_._._......................... Phone: ................... Mach. Htg./Coolg. Permit $............................. $........ Engineer: Residential Construction Tax .............,.. ....._............$..._..-.._ ..._.. .. ........................ ......__............................. Phone:...............wn Mise. Fee ..........._.................. ;i l(: U 4ti.! $_. ... �:.... .... . . .er_._..nee ... a E) Unknown i ` •• $ Lender: certify that in the performance of the work for which this permit is Misc. Fee ._._..... .-..... ......... .. issued I shall not employ an p y y person in any manner so as to become sublet( • • : h h, $aA S-0 U the workman's mpensation ws of California." SIGNATURE OF y Le ,J/���� ZONING • .__..._.._.... APPLICANT/OWNER `^"' - ' /' 6C.AAt� .... DATE?.................. -ov Environmental Status: Exempt ........_ Other..................... .. I certify that as the applicant I am licensed uncle the provisions of the Design Review Approval: Bldg. _.......... Site ............ Sign ...._...... Contractors License Law and further that my Licens. No. ......_........_......... Use Zone ............ P.D. Conditions ......_____.... ............____..........:.... m Classification _.... ......_...._._............ is in full force and effect: or Cond. Use Permit #........... Variance #.. ........ Parking Spaces............ I certify that I am exempt from the "Licensed Required" provisions of the Approved By. " "'"""""""'"' Date Contracmra License Law. (State basis of exemption.) -- --' '-"'-"' I hereby acknowledge that I have read this application and stale that the above is • . :orrect and agree to comply with all City Ordinances and State Laws regulating building. roachment Permit.,...................... Grant Of Easement ........... 1 (We) agree to save, indemnify and keep harmless the City of Cupertino _..._ _.... against liabilities, judgments, costs and expenses which may in any way Orb, Gutter, Sidewalk, Driveway: Replace.......... Repair.......... accord 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 • ' 120 days from validalion date, or should authorized construction be suspended or abandoned for a period of 12D days after work is commenced. PERMIT INSTALLATION NO, EACH FEE Light Outlets............ Switches............ APPLICATI• • • 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. ............. 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.L....... 7.00 .... Sewer .........._............... __ Time Clock ......___............................_.... .......__............. 1.50_._.......... Lawn Sprinkler Sys. $5.00 Ea. atltl Sys. $2.00......... ............ ............. Misc. see Ord. current 1..............Rate...... .. ............. Vacuum Breakers ....._ .....................3.50.............. New Residential Occupancies Flat Rate Interceptor........ Water Softener,....... ....... ...........4.00. ........... ............ Plumbing Piping without fixtures ....................... ............4.00............... 0-500 aq. ft. $22.00 1501-1750 $34.50.............................. Misc. (See Ord. Current) .......... 501-750 24.50 1751-20000 37.50.............................. .......................................... 751-1000 26.00 2001-225C 39.50........................ ..... Permit Fee _..........................................$6.00 1001-1250 26.50 2251-2500 42.00......................... TOTAL PLUMBING PERMIT FEE (plus penalty if app. ❑) $ 1251-1500 32.00 2501-2750 49.50.............................. APPLICATION •, •• PERMIT PermitFee...............................................$6.00 TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.p) $ PERMIT INSTALLATION NO. EACH FEE INSPECTIONRECORD .................. Forced Air Unitto 100M ..............................$6.00............... over100M........................ . 10.00.. ......... Forms / Foundation Comfort Cooling Unit .to 3 ton/HP ...........__.......... . 6.00............... Plumbing Grroundound . ........ . ..... . ......... to 15 ton/HP......................... 9.50.............. WWork . ..................... ................. j.. ... ..... . By: ..........._... Date: ....... ....................... -- to 30 ton/HP... ..... 12.00. Ro gh Electrical ..._ .... ... e - Plumbing and Heating _i to 50 torl.... ... . ... 17.00 ..._ "" S ace Heater..han Wall Heater ...... "... 6.00 • etian & Energy. . . . .. -� � p ��� -- ------ Flues - other than above oaslTest .........._... ................. .... .. � .. 3.00.............. ....__....................._..............._.. Vent Fan: Kitchen........ Bath .... ............. Temiorary Power Gas / Elect. ..__. ........... 3.00'.............. C......... ` Final- Electrical _ _ j --- ...." Commercial Range Hood ...._........._..............._. .1._ 6.00..,., Final- Building/ Mechanical .. _ ....... "".""�� Mise. (See Ord. Current.... ..,_ j Final• Design Review / LandscaPmg .... .. I ---- ..... Permit Fee .. _... .... .. - $ 6.00 -------- TOTAL Htg./ Coolg. Permit Fee (Plus penalty i` BPP• ❑) $ F\i/n)al-Public Works ........................................................... Sheet, 2 r CITY OF CUPERTINO BUILDING PEr2,1IT Permit No: �3 Address: /og-0/ E r ESTF1 TcFZS OK • Date: 8-8- S10 BUILDING PROJECT IDENTIFICATION WORKERS'COV PENSATION DECLARATION Applicant's Mailing Address /OHO/ Cc C UPE'/ //NU /-ic. 'Yia 1 hereby affirm that i have a certificate•,:P consent to self-insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof (Sec 600 Lab.C.' Address of Building Policy No. Cumpanv Oscner's name 27 HG. Certified copy is hereby furnished. ecAdO Certified copy is Bled with the county building inspection Telephone No. 6-16�1-6 V60 department or county department. Contractor's Name Date Applicant Contractor's Mailing Address CERTIFICATE OF EXEMPTION FROM WORKERS' Lic. Na. COMPENSATION INSURANCE (This section need not be completed if the permit is for one Architect or Engineer hundred dollars (S100) or less.) Architect's or Engineer's Address 1 certify that in the performance of the work for which this permit Lic. No. is issued,I shall not emplov any person in an% manner so as to become subject to the Workers' Compensation Laws of California. LICENSED CONTRACTORS DECLARATION DateCApplicant : , I hereby affirm that I am licensed under pros isions of Chapter 9 NOTIE TO APPLICANTIfafter making this Certificate of 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 my license is in full force and effect. comply with such provisions or this permit shall be deemed revoked. License ass Lic. Number _ Date Contractor CONSTRUCTION LENDING ACENCI' I hereby affirm that there is a construction lending agency for the Performance of the work for which this permit.is issued (Sec.3097, OWNER-BUILDER DECLARATION Civ.C.). Lender's Name I hereby affirm that I am exempt from the Contractor's License Lender's Address - Law for the following reason (See.7031.5,Business and Professions Code: Any city or county which requires permit to construct,alter, 1 information that [have read this application and state that the above �lmprove,demolish,or repair any structure.prior to its issuance,also ordina ces n correct. 1 agree to comply with all city and n,county ordinances and state taws relating to building construction, and requires the applicant for such permit to file a signed statement that hereby authorize representatives pe this county to enter upon the he is licensed pursuant to that provisions of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the aboveKnentioned property for inspection purposes. Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 70315 Signature of Applleeat or Agent pate by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 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 - intended or offered for sale (Sec. 70.74, Business and Professions "Attention Property Owner: Code: The Contractor's License Law does not apply to an property who builds or improves thereon,and who does suowner of An 'owner-builder' building permit has been applied for in ch 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 for sale.If,however,the provided at your earliest opportunity to avoid unnecessary delay budding or improvement is sold within one year of completion,the in Processingand issuing your budding 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. or improve for the purpose of sale.). L I personally plan to provide the major labor and materials for ❑ 1,as owner of the property,am exclusively contracting with _ construction of the proposed properly improvement (yes or no) licensed contractors to construct the project (Sec.7044,Business and Professions Code: The Contractor's License Law does not apply to 'L 1 (have/have not) signed an application for a an owner of property who builds or improves thereon, and who building permit for the proposed work contracts for such projects with a contractor(s) licensed pursuant to 3. 1 have contracted with the following person (firm) to provide the Contractor's License Law.). 'the proposed construction: F1 am exempt under Sec. , B.&P.C. for this Name reason Address City. Dat -7- Owner A-�A'^/� 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 1 have contracted(hired) the following persons to provide the work indicated: Name Address Phone Type of Work Signed: Property owner Social Security number Date: