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1082 CITY OF CUPERTINO APPLICATION FOR :RESIDENTIAL BUILDING PERMIT PERMIT NUMBER lo" S • AND R APPLICANT TO FILL IN CERTIFICATE OF OCCUPANCY BUILDING INSPECTION DIVISION ' STREET ADDRESS OF PROJECT: 26 .hem ,v r • • • • Legal Description: Tract........................ Block............ Lot................... Description of Work: ................ ... ......... .... . .. Plane Received B ......... ...................................... t y � Dae ......................... ........................................................ REO.: Plane.... Survey.... Calcs: Struc..... Energy.... Elect..... Mach.... 1st Struct. Improvement on Parcel: as.... No.... Area of Bldg............... Plans Checked By........................ .. Date ..... ...... . . Separate Structure............ or Addition/Alteration to Exist. Bldg........... Application Approved By..L..... ... .. .�.........Date ... . ... No. of Stories.............. . U o uildin Q � tg g .. ...... ... .. ........ Validated By.............................................................Date ........................ ValuatP I ect: Owr: -j _ Y.�...,�ND..O ..OJ -�......._.... Phone:.................... Compensation Certificate Verified BY ................. Date ................... ................................. .... Contra : ..............................................:........City Bus. Lic. x'.............. e . • ' • .... Contra or'S Address: ................................................ Phone;..............------ -- O� Contractor - Electrical: Permit Fee (plus penalty if applicable) ......._'.-:T^ $...:Z.T....... .............................................................................. Plan Check Fee (less deposit of$.i ..-Rct. #..........� I$................... City Business License e.................... Phone:.................... Energy Plan Check Fee (Dep.of�S.....1.:Rc7�.^� .0....)$....................... Plumbing: ...................................................................................... Strong Motion Fee ....................... rU ..$.........y.S ... City Business License x,,,.,._............. Phone:.................... Heating and Cooling PlumbingPermit Fee ........... .................................................................. n.... $....................... l......'"'"'/�"' ""'.... City Business License ...................... Phone:.................... Electrical Permit Fee ........................:........�.... .. ..$...................... Mach. Htg./Coolg. Permit $.............................. $....................... Architect: Designer: .................................................. Phone:.................... Residential Construction Tax ........................................$....................... Engineer: ..._............................................................... Phone:...............wn Misc. Fee $............ lender: . ..certify that ...........performance erf .......................................... c this Unknown "' "I corlI s than in the y any person of the work for which eco Permit Is Misc. Fee ��' """'"""""'"""""'"""""""'""""""""'"""""""""$""" —�""--� issued I shall not employ any person In any manner so as to became subject • • : $ 30,-5-0 to the workm compansallon ws of California." SIGNATURE OF � I ///Q • • AlL PPLICANT/OWNE _......... .._. ............... DATE��_!..J. e) 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 Cond. Use Permit e.._........ Variance »--- Parking Spaces............ .... I certify that I am exempt from the "Licensed Required" provisions of the Approved 8 Contractors License Law. Island basis of exemption.) PP Y-.............._.........._.............._......... Date ........................... I hereby acknowledge that I have read this application and state that the above is WORKS REQUIREMENTS aonecn and agree to comply with all City Ordinances and State Laws regulating PUBLIC building. I Iwo) agree to save, Indemnify and keep harmless the City of Cupertino ncroachment Permit....................._.. Grant Of Easement........................ against liabilities, judgments, costs and expanses 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 $................ SICNATURF 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 APPLICATIONe 170 days from validation date, or should authorized construction be suspended or abandoned for a period of 120 days alter work Is commenced. PERMIT INSTALLATION NO. EACH E APPLICATION • , PLUMBING Light Ou ets............ Switches............ Fixtures...... ..... Receptacles....:....... PERMIT INSTALLATION NO. EACH FEE TOTAL MBER (less than 1000 watts) ....... ... $ .50 .......... Gas System with up to 5 outlets .................................$4,00 ............. Range........ Co 'ng Unit........ Oven............ ...... . ....... 2.00 .............. Each additional outlet ............................................. 1,00.. ......... Dryer......-. Garb. p......... Dishwasher ..... ...... ........ 2.00 .............. Water System (Installation, Alt. or Repair) ................. 4.00-.............. MOTORS: 1 HP or s .......................... .................... 2.00 .............. set.... Water Heater.... Ld. Tray................... .00. ............. Greater than 1 HP t more the HP .............. . 3.50 .............. Lavatory.... o athtub.... Sink........ ........ 3.00. ............. Temporary Power Pole or rvic 100 amp ........ ..5.00 .............. Wash. Mach..... Dishwasher.... a ............ 3.00............... —200 amp........ . 7.00............... Sewer ............................................... ............................ .00............... Time Clock ..............._........ __....... ..........._.................. 1.50............... Lawn Sprinkler Sys. $5.00 E d Sys. $2.00..................... .... .... Misc. see Ord, Curren .............. ...................................... Vacuum Breakers ........ . ............................... ..............3.50.............. New Residential Oc ancies Flat R Interceptor........ W Softener........ ................. ............4.00. ............ Plumbing Pip' without fixtures ...................................4.00............... 0-500 sq, ft. $ .00 1501-1750 $34.50. ........................... Misc. (S rd. Current) .................................................... 501-750 4.50 1751-20000 37.50..... ....................... mit Fee ..........................................................................$ 6.00 751-1000 28.00 2001-2256 39.60........ .................... 7 AL PLUMBING PERMIT FEE (plus penalty if app. Q) _ 1001-12K 28.60 2251-2500 42.00.............................. 1251- 00 32.00 2501-2750 49.50.............................. APPLICATION FOR HEATING/COOLING PERMIT PermitFee...............................................$6.00 TOTAL ELECTRICAL PERMIT FEE (Plus penalty If apl $ PERMIT INSTALLATION 11NO. EACH FEE Forced Air Unit..................to 100M ..............................$ 6.00. ............ INSPECTION RECORD over 100M ................. .. . 10.00.............. ' C ..... Comfort ng Unit 3 ton/HP ................. ........ .. 6.0 . ........... Forms Foundation ............................ . BY:........ ....... . Date:................ to 16 ton/HP...................... o.. ............ Plumbing Ground Work . .___............. . .._..........., ............. .....,. "" 30 ton/HP........... Rough Electrical _. ..12.00.-L.:...... _ ........._._....;......_....._.. _....................... .........................- to /HP 17.00.. arae - Plumbing and Heating '��""�""""""" """""' .......... ......................... ........................... Space'Heater........ Well Heater .... ........................ 6.00... •u nation 8 Energy,....:................... .. ........... above above . ... ... ..................... ........................... Vent Fan: Kitchen. ... ath .................................. .. 3.00.............. Final - Electrical ._....... .... . ........................... ........................... Flisc ..... 6.00..._......... othe 'as Test . ............ .. .. ...,..... _..._. Temporary Power Gas / Elect. ...........................................:........ Cbmmerolalr �e Hood 3.00'...... ............ ........................... ......... M Ord. Current............................................ .. ' Ina - Design / Mechanical ..........g .................................................... Permit Fee ............. _ 00 Final - Design Review / Landscaping ........................................... TOTAL Htg./ Coolg. Permit Fee (plus penalty app. E]) $ Final—Public Works ........................................................... i f