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1078 CITY OF CUP ER O APPLICATION, FOR RESIDENTIAL BUILDI G PERMIT PERMIT NUMBER 0 -� AND • . APPLICANT . CERTIFICATE OF OCCUPANCY FILL IN BUILDING INSPECTION DIVISION STREJ7 D��qR,�S S f]F PROJE�y '.. .9..y�7...... ._ A.......ffl.i.- ...__....................... DEPARTMENT • Legal escrlption: Trac ......... -. p� ......................_.......... Lot......__.. Plans Received By................................................... Dete ...................._ A Description of Work: l,( e• .......................... REO.: Flans.... Survey.... Cafes: Struc......Energy.... Elect..... Mach.... 1st Struct. Improvement on Parcel: Yes.... No... Area of Bldg............... Plans Checked By..._.........._.... ... __.......Date .._. ... .. Separate Structure............ or Addition/Alteration to Exist. Bldg........... Application A roved B Qx.z -ria � .. ......... ......................Data ... PP PP y.- a f No. of Stories. ........ Use of Building ..__ ....... __.......... Validated By ...... ............. . - .. ....Date -..... Valuation f Project: Compensation Certificate Verified By ... Date ........ Owner: . .. Phones 711 I ....j ,(q . . •• f Contractor: f 11C f/b (�.f;✓�L�q1��tty Bus Lla * Contractor's Address �. .� F/y/- .r�.: PhonetP�,1 � Permit Fee (plus penalty if applicable) Contractor - Electrical: ....... ............. _.._.........._.......................... Plan Check Fee (less deposit of$.......... Rct. #.... E.............. ...... Cit/ Business Licens$ .............. Phone:.._......____ Energy Plan Check Fee (Dep. of $........ Ret._#........ $............._ ....... Plumbing: ................. �i.. . . ....... _..................... _..... Strong Motion Fee ............._........... c:•�:• -t,•.....$..............___..... City Business License �.�4"7.. Phone:......... p.OQ Heating and Cooling ..........._.._.... ._......_........................_.... Plumbing Permit Fee ................ ....... .... ..._..$ ...... _..... Electrical Permit Fee ....... ............_.�1.1p!._�..y..�'%?�L�.E.... ......... ........ City Business License *.................... Phone:............. J VIt Mach. Htg./Coolg. Permit $....... ............. Architect/Designer: ......_...................__......... . ... Phone:.................... ....... .. _ __$....................... Engineer: ... Phone:....-............ ... Residential Construction Tax ................... . ............................_.....................__...... � 1,........._--,. ..._._............... Lender: � 'Unknown Misc. Fee - ..�..._.......$. . .. . ...__................erfo ..........f the..............._..... .._........................................r............ _.......__...._.. "I certify mel In the ... y performance of the work for which this is - Misc. Fee ..._.........__.........__........__.........__................$..._.................. issues I shall not employ any Person in any manner so as m becomea subject aublect • $ to the workman's compensatlon laws of California." SIGNATURE OF • • APPLICANT/OWNER ........__......................................................__ DATE._........ L.._.._... Environmental Status: Exempt ....._..... Other... .................................... ,,... "I certify that as the applicant I am liconsed unde the provisiony of the Design Review Approval: Bldg. ..... .. Site ............ Sign ........ Contractors License Law and further that my Users, No. .. �..�. Use Zone ............ P.D. Conditions In Classification ._................................... Is In full force end a fact: or Cond. Use Permit *............ Variance *.... _..... Parking Spaces............ t 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 acknowledgo that I hove read this application and state that the above is _ eoriect 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 rODChmant Permit..._................... Grant of Easement........................ against liabilities, judgments, costs and expenses which may in any way nb, Gutter, Sidewalk, Driveway: Replace.......... Repair.......... secure against said City Aconsequence of the granting of this permit." Sewer............ Cann. Fee $.._........... Water.._............ Meter f................ SIG NATUflF. OF 1 ��//�� Agreement for Completion of Public Works Improvements ......._......... APPLICANT/CONTRACTOR /i� TFlJ...rJ ...... Plans Checked By........ Date........ Approved By........ Date.................... NOTE: whenproperly dates this form coni a. a eallainp pennll. This permit expires and b s null and void should rk not be eomn•nced within • • - 120 days from valid date, or should authorized construction be s r•Vend•d or abandoned for a period of 120 days after work is commenced. PERMIT INSTALLATION NO. EACH FEE APPLICATION , Light Outlets ... Switches............ 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 His ordess .................. ...........___... ....... . 2.00 _ ............ Water Closet.... Water FteaterlX0 r�Tray..................... 4.00. -fit:. . 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. add Sys. $2.00..................... ............. Misc. (see Ord. current )...................................................... Vacuum Breakers......-...................................... .. ............3.50. ............. New Residential Occupancies Flet Rate Interceptor........ Water Softener........ __....................._..4.00. ............ Plumbing Piping without fixtures ................__........_.....4.00, _ 501-7 0 ft. E22.50 1501-1750 $34.50.............................. """"-"' Misc. (Sae Ord. Current) .................................................... 501-750 24.50 1751-2250 37.50.............................. Permit Fee 751-1000 26.00 2001-225G 39.50.............................. .........._ " ..........................�........--.-.....-..-.E 8.00 1001-1250 28.60 2251-2500 42.00.............................. TOTAL PLUMBING PERMIT FEE (plus penalty it app. C)) f &Ix 4 1251-1500 32.00 2501-2750 40.50.............................. APPLICATION . . PERMIT Permit Fee...............................................$6.00 TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.p) $ PERMIT INSTALLATION NO. EACH FEE Forced Air Unit__..............to 100M ..................... .........$ 6.00... ............ • • ' ' over 100M _...................... . 10.00.. ........... Comfort Cooling Unit......to 3 ton/HP ................. .......... 6.00... ........... Forms Foundation ............................ 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.. ........... ne - Plumbing and Heating .......... ......................... ........................... Space Heater........ Wall Heater .........................I. ....... 6.00.. .. on 8 Energy........................_.... .... ...... ..._..........._...... Flues - other than above ....... �.. 3.00.. .. ai. Test ................._......_.._. . .................__........ ...._. ......... .. ...... ._. ..........._..............._...._....... Vent Fan: Kitchen........ Bath ............._........ ..... ...._.. .. 3.00............... Temporary Power Gas / Elect. ..._... .__._.........-_.....�........................... Commercial Range Hood 6.00 ................................... ............... Final - Electrical ......_.......__................. ............._........ ............._........... Misc. See Ord. Current .._....__.....�...__.......___.$ 6....._.. Final - Building/ Mechanical .....__.... ......................._....__................ Permit Fee ..___...... , f B.00 Final - Design Review / Landscaping . .... . ...................._.........._........ TOTAL Htg./ Coolg. Permit Fee (plus penalty if app. ❑) $ Final— Public Works ...........................................................