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1373 CITY OF CUPERTINO APPLICATION FOR RESIDENTIAL BUILDING PERMIT PERMIT NUMBER /3 3 AND FOR APPLICANT TO FILL IN CERTIFICATE AND OCCUPANCY BUILDING INSPECTION DIVISION ST EETDRES OF F�OJEC .. ..9. ......... �..E�...r.........G.. .................................... r • • • . Legal Description: Tract-.......... BBI�I44 k_.._...t. Lot...... ..._..-- Description of Work: (�.,c�.CQ. ..S•V. .S...x tass.S I�. Plena Received By..................................................Date ....._.......... ......1..._......-... .._.. } - .. .. REQ.: Plana.... Survey.... Cafes: Struc..... Energy.... Elect..... Mach.... 1st Struct. Improvement on Parcel:Yes.Y. No.. Area of Bldg..`0.6..... Plans Checked By......................................-...........Date ......-...-........... Separate Structure............ or Addition/Alteration to E Ist. Application Approved By......................................... _ _ Date ...-............ ... p 9....... No. of Stories......k.... ... Use of Buildin S.f.nyl.e.. vr4X. Validated By.............._.............................._..._.........Date ............_........._ Vatuatio of Projec $.. (P ........_._................ .................. Compensation Certificate Verified By ... ...... Date ........._............ Owner: �1(fxPer�� .. .... .. ... Phone�S..-?q�• $ �Loloy.tm y Contractor:�off.�^ . 5.. .� City Bus. Lic. N INV?, • • ' - a / Contractor's Address:Ry.Bu,.l3�$.. .!•e_ .:.._........ Phone:/vs].i.r.» Permit Fee (plus penalty if applicable),.....__.........._...$.... Contractor - Electrical: ........-.......... ................_....-............................._. Plan Check Fee (less deposit of$... ! $.............. . City Business License a ....... _ ........... Phone:.................... . '._ RcL• ,. ... ...) Energy Plan Check Fee (Dep. of $........ Rct. *n... r$....................... Plumbing: .._...._..__..................._............_............__................_. Strong Motion Fee .......... .......... f _..$----------------------- City Business License *.._.._ ...._-- Phone:-.... .. 1 &-�tOO Heating and Cooling ...._.............................._....__....._............. Plumbing Permit Fee ............_....._. ........._j..�I'>...$..........._.......... City Business License s........_...._._. Phone:.................... Electrical Pemnit Fee ....._............. ...._..... .. :. _-...$---....._...._.... '� Architect/Designer: .... --.. .. Phone'-.. .. Mach. Htg./Coolg. Permit $ .......p......... $ -- ... Engineer: .... _ .._ .. - .. Phone: .. .. Residential Construction Tax - ..._.... -..$.. - .......... Ler. . .. .. .. ..... ._...._....-. .._.........._ Unknown Misc. Fee ..................................... ... .......... $...... ......... l _ yy.. AA IF AAm�y .. "I certify that in the performance of the work for which this permit is Misc. Fee ............................_._../.\.I�.M..../....0 --.$..-�,y-U .. Issued I shall not employ any person In any manner so as to become subject • . ; E �� f5� to the workman's compens atl n laws of Gulf refs." SIGNATURE OF orz• s _........... APPLICANT/OWNER ......................_. ... .. DATE.. ... - ....... Environmental Status: -Exempt........_.. Other...._._..... .. . -I certify that as the applicant am Ilcenaed unde the provl9 e f the Design Review Approval: Bldg. ..... ..... Site .._........ Sign ....-....- Contractors license L w d further that my Licens. rbc AIQ . Y__........ Use Zone ............ P.D. Conditions ....................................... .... in Classification ....... .,..........-..... is in full force and effect: or Cond. Use Permit If.........-. Variance #..._....... Parking Spaces........:... I I certify that I am exempt from the 'Licensed Required" provisions of the Approved B Date Contractors License Law. (State basis of exemption.) PP Y..._..._............._..._..........__............... __....._..........._... I horeby 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. ( (We) agree to save, Indemnify and keep harmless the City of Cupertino Oroachment Permit............_......... Grant Of Easement..................._... against liabilities, judgments, costs and expenses which may in any way Orb, Gutter, Sidewalk, Driveway: Replace.......... Repair......._. secure against said City In consequence of the granting of this permit." Sewer............ Conn. Fee $............._. Water................ Meter $.... .... SIGNATURE of /S — Agreement for Completion of Public Works Improvements ......_....._... APPLICANT/CONTRACTOR Z/.•.C. ..._........_/........... .............. DATE _ ........... Plans Checked By........ Date........'Approved By........ Date................... NOTE: when properly validated this fore, constitute. a Building ParmH. This permit expires and becomes nun and void should work not,be comnumctud wnhln APPLICATION • - ELECTRICAL PERMIT 120 days from validation date, or Mould authorized construction be ausptndad or assasabandoned for a period of 120 days after work Is commenced. PERMIT INSTALLATION NO. EACH FEE APPLICATION a • 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.o0 ............. 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.o0 -......-.-... Water Closet.... Water Heater.... Ld. Tray.-............-... 4.00 .......... Greater than 1 HP not more than 5 HE ..-........ . 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. at:n...... —200 amp........ . 7.00.............. Sewer .......... -...........-.... ..........._................. . 8.00 Time Clock _.................---......_...._..................._......... . 1.50............... Lawn Sprinkler Sys. $5.00 Ea. add Sys. $2.00..................... ............. Misc. (Bee Ord. current)...................................................... Vacuum Breakers ...3.50. New Residential Occupancies Flat Rate Interceptor........ Water Softener........ .............................4.00. ............ Plumbing Piping without fixtures ............4.00.,.,.,,, 0-500 eq. it. $22.00 1501-1750 $34.50.............................. Misc. (See Ord. Current 501-750 24.50 1751-20000 37.50.............................. . Permit Fee 751-1000 26.00 2001-225C 39.50.............................. ..._...._............_............................................alt ...E 8.00 1001-1260 28.60 2251-2600 42.00.............................. TOTAL PLUMBING PERMIT FEE (plus penalty If app. �) _ 1251-1500 32.00 2501-2750 49.50.............................. a a PermitFee...............................................56.00 TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.0) $ PERMIT INSTALLATION N0. EACH FEE Forced Air Unit..................to 100M ..............................$6.00... ........... INSPECTION RECORD over 100M ...................... . 10.00.. ........... Comfort Cooling Unit.....So 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.. ........... ame - Plumbing and Heating ...._....I......__.............. ........................_. Space Heater........ Well Heater ..................................I 6.00.. ......... ulation 8 Energy..........._.................. ...._..........._...... ...._..._............-... Flues - other than above ....._.._........_._...................-I-. 3.00.. ........... asTest .......... .............._................ ............_....,.._.'... ......._...__..._.. Vent Fan: Kitchen........ Bath ............................. ..._.. .. 3.00............... Temporary Power Gas / Elect. . ........ ........................ .......................... Commercial Range Hood `. 6.00............... ................._...................... Final - Electrical .................................. ....................._.. ........................... Mise. (See Ord. Current............._........_..__...._...._......._._._............... Final - Building/ Mechanical .__...... _............... Permit Fee . . _....._... . .... ..... ...... .....,.._.... $ 6.00 Final - Design Review / Landscaping . ...... ..... TOTAL Htg./ Coolg. Permit Fee (plus penalty if app. p) $ . ................................... Final- Public Works ........................................................... Sheet 2 CITY OF CUPERTINO/ BUILDING PERhIIT Permit No: Address: )gKC75 r16. • Date: BUILDING PROJECT IDENTIFICATION WORKERS' COSI PEN'SATION DECLARATION Applicant's %failing Address I I hereby affirm that I have a certificate r:consent to self-insure, or a certificate of\Porkers'Compensation Insurance,or a certified �x ropy thereof (Set 500,Lab.CJ. Address of Building • Policy No. Company Certified copy is hereby furnished. Owner's name — — -- Certified copy- is filed with the county building inspection Telephone No. SSA— �rs5—a dap tqm�/geJ/sst county � dep��r�tpypwYgqt. Date '/ Applicant ,�� Contractor's Name �..q // --I— Contractor's Slai O Address f a 1� CERTIFICATE OF EXEMPTION FROST IVORKERS- Lie.No. s�/x 19a/� COMPENSATION INSURANCE (This section need not be completed if the permit is for one Architect or Engineer hundred dollars ISM) or less.) Architect's or Engineer's Address I certify that in the performance o(the work for which this permit Lic. No. is issued.I shall not employ any person in any manner so 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 1 am licensed under provisions of Chapter 9 Exemption,/� you, should become subject to the Workers' t:' (commencing with Section 7000) of Division 3 of the Business and Compensation provisions of the Labor Code, you must forthwith License Class Lie. \uer /5Professions Code,and�ny license is in full force and mbareffect L comply with such provisions or this permit shall be deemed revoked. - Date _4L, r, Contractor CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agenev 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 Contractors License Lender's Address Law for the following reason (Sec.70315,Business and Professions I certify that 1 have read this application and state that the above Code: Any city or county which requiresa permit to construct,alter, information is correct. 1 agree to 'mprove,demolish,or repair any structure,prior to its issuance,also comply with all city and county ordinances and state laws relating to building construction, and equires 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 prosisions of the Contractor's License above-mentioned property for inspection purposes. Lase(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031. 51gsutare a AppU,r.t or Agent Date by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5.500).): 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. 7044, Business and Professions "Attention Property Owner. Code. The Contractor's License Law does not apply to an owner of "An 'owner-builder' building permit hu been applied for In Property who builds or improves thereon,and who does such work your tame and bearing your signature. himself or through his own employees, provided that such Blease 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 building or improvement is sold within one year of completion,the In Processing and tssuingyour 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 receive& or improve for the purpose of sale.). L I personally plan to provide the major labor and materials for ❑ I,as owner of the property,am exclusively contracting with comtruclion 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 2 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 9 1 have contracted with the following Person(firm) to provide the Contractor's License Law,), the proposed construction: ❑ I am exempt under Sec. , B.h P.C. for this Name rcasnn __ Addresa City, Dat,.. Owner Phone Contractors License No. - - 4. 1 plan to provide portions of the work, but I have hired the following person to coordinate,supervise, and provide the major Work. Name Address City 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 Ty pc of Work . • Signed: Property owner Social Security number Datc: