1541 CITY OF CUPERTINO
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APPLICATION FOR RESIDENTIAL BUILDING PERMIT, r PERMIT NUMBER
AND� • .� CERTIFICATE OF OCCUPANCY �
APPLICANT TO FILL IN
BUILDING INSPECTION DIVISION pi'�STREST ADDRE S QF�PR•O�ECT:
a • - • Legal Description: Tract. ..... ......... Block........__-Lot... .. ..�....._.
Plans Received By .................................... ._...Date .. D._a. VW_W r_k_:..-Wal_ .ee�.........-
.....
......................... ..
REO.: flans.... Survey.... Calcs: Struc..... Energy.... Elect..... Mach.... 1st Struct. Improvement on Parcel: Yes. .. ... Area of Bldgldg..TVA—
Plans
Checked By..........................-....-.................Date .....................- Separate Structury_........... or Addition/Alteration to Exist. Bldg...........
Application Approved By..............-.........................Date ......................._ No. of Stories....... ..._.. U f ridin
Validated By..............................................................Date ........................ Valuation o Pr act: riding ............
Compensation Certificate Verified B
P Y ................. Date ................ Owner: MI _..... .S� � {lIZ}2__........ Phone:�'�.:...
_ Contractor: A Qn� .. ...City Bus. Lic. •1
• • • $ Contractor's Atltlress: as .�..-.�...(5... ........ Phone:995-
Permit Fee (plus penalty it applicable) ................ $................ Contractor - Electrical: ......._.......................................1...........-..............
Plan Check Fee (less deposit of $.......... Act. A..........)$............._.. City Business License ....... Phone:....................
..
Energy Plan Check Fee (Dep. of $........ Act. #........)$...- Plumbing:...
... 9: ._...._................ ........._......_..._....................................
Strong Motion Fee ..........................................................$...... .... City Business License x.................... Phone:....................
Heating and Cooling
E '
Plumbing Permit Fee ................................................$...../... .... City Business License w.................... Phone:....................
Electrical Permit Fee ..................................... ...............$....... ............_.. Architect/Designer: ............................................... Phone:....................
Mach. Htg./Coolg. Permit $............................. $-.....................
Residential Construction Tax .._............................_.....$......-....-...... . Engineer: ._ ........_ ..................... .........._................... Phone:................_.
Lender: ... .........._..._._._._..................._............................
Misc. Fee ..........................:.............................................$....................... nknown
"I conif that in the
.... ... y performance person
al the work for which this permit le
Misc. Fee ....._......._........._.............................................$...... issued I shall not employ any person In any manner so as to become aublect
• $ to the workman's compensation laws of Cafllarnie."
SIGNATURE OF Q� 'A a
• • - APPLIC T/OWNER �.''V.L:C' Il....124'1W..._..................... DATE._LO.�a..1..�9.
Environmental Status: Exempt ............ Other........................................ .. "I conify that as the applicant I am licensed undethe p�vjgl lip ¢ �t�he
Design Review Approval: Bldg. ............ Site ............ Sign ............ Contractors LicentW gn�tudhgr that my Licens, No. .....�..IL..H...✓....... ....
Use Zone ............ P.D. Conditions ............ in Classification .. d�� DDC�..9Y'...... is in full force and effect: or
Good. Use Permit •............ Variance 0............ Parking Spaces............ - - I corhb, that I am exempt from the 'Licensed Required" provisions of the
Approved By. Date Contractors License Lew. (State basis of exemption.) .
""'"""""""""""""""""'"'""""""""""" """"'-""'"""""""-"" I hereby acknowledge that I have reed this application and state that the above is
correct and agree to comply with all City Ordinances and State Laws regulating
• ' • building.
Ill
x I (We) agree to save, Indemnify and keep harmless the City of Cupertino
tcroachment Permit ... Grant of Easement............... ........ against Ilal llltiea, judgments, costs and expenses which may In any way
_.irb, Gutter, Sidewalk, Driveway: Replace.......... Repair.......... secure against said City in consequence of the granting of this permit."
Sewer............ Conn. Fee $................ Water................ Meter $................ SIGNATURE OF >41
A t �
Agreement for Completion of Public Works Improvements ........_._._.. APPLICANT/CONTRACTOR l ..._. ............._..^.. ......._............ DATE ....._...._...........
Plans Checked By........ Dale........ Approved By........ Date.................... NOTE: When properly validated this farm constitutes a Splicing Permll. This
Permit expires and becomes null end void should work not,be commenced within
• • 120 days from validation date, or should authorized construction be auap•nded or
abandoned for a period of 120 days after work Is commenced.
PERMIT INSTALLATION NO. EACH FEE
Light Outlets............ Switches............ PLUMBINGAPPLICATION FOR
Fixtures............ Receptacles............ t 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......... 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 Flat Rate - Interceptor........ Water Softener........ ................. ............4.00.
............
Plumbing Piping without fixtures ...... . .......... ..............................4.00. ..............
0-500 sq. ft. $22.00 1501-1750 $34.50.............................. Misc (See Ord. Current)
501-750 24.60 1751-20000 37.50.............................. ..........................................
751-1000 26.00 2001-225C 39.50.............................. Permit Fee .........._._.....................-......................................$ 6.00
1001-1250 28.60 2251-2500 42.00.............................. TOTAL PLUMBING PERMIT FEE (plus penalty if app. 0) $
1251-1500 32.00 2501-2750 49.50.............................. APPLICATION • . •• PERMIT
Permit Fee...............................................$6.00
TOTAL ELECTRICAL PERMIT FEE (Plus penalty If app.E]) $ PERMIT INSTALLATION NO.FCHFEE
Forced Air Unit.........__.._.to 100M .....__............ ........NNKMMNM
• • - r over loom .....-................Comfort Cooling Unit......to 3 ton/HP ....................�....Farms / Foundation .............................. By:........ ....... . Date:................ to l5 ton/HP................. ...... ..Plumbing Ground Work ...................... .... '.....""................ ...................._.._. to 30 ton/HP._............. ....... ..........
oulectrlcal ..... ..........g .................. ... ......................... ........................... to 50 ton/HP......................... ...........
•afigme - um ng an eating .......... .................................................... SPace Heeler......._ Wall Heater ................................... . .:
...........
s talion & Eliar................................... ......................... ........................... Flues - other than above ............................................ . 3.00.. ............
as Test _...................................... ... .. .,.........._..........1..,..........._._........ Vent Fan: Kitchen....... Bath ............................... ........ .. 3.00...............
J Temporary Power Gas / Elect. . ................................ ........................ . Commercial Range Hood 6.00... ............
Final - Electrical .............................................................. ............-............. Misc. (See Ord. Current...-.............................................,.- ....... ............
Final - Building / Mechanical ....................................... ........................... Permit Fee $ 6.00^n
.._..........._.........._......._.....nalt.........pp........ /1
Final - Design Review . Landscaping . ...... ............................_....._...... TOTAL Htg./ Coolg. Permit Fee (plus penalty if app. �) $(a.,
Final- Public Works ...........................................................