1765 CITY OF CUPfRTINO v,
CITY OF CUPE•NO lgNl •
v APPLICATION FOR RESIDENTIAL BUILDING PERMIT p PERMIT NUMBER 176 s-
iAND L
FOR APPLICANT TO FILL IN
CERTIFICATE OF OCCUPANCY
BUILDING INSPECTION DIVISION STR ET ADDRESS' OF PROJECT:
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1.7 90. . .viV..7!(0..._0....L
..(...f.f.......lW.... ...................
• • Legal Description: Tract_..................... Block............ Lot......................
Descriptl of Work: .. ...............
Plans Received By....................................................Date .........................
REO.: Plans.... Survey.:.. alts: Struc..... Energy.... Elect..... Mach.... 1st Struct. Improvement on Parcel: Yes.... No... Area of Bldg...............
Plans Checked By......... Q to .... ................ Separate Structure........ or Addition/Alteration to Exist. Bldg...........
Application Approved By ......... ............. .... ata ..S.W1U...1'7ef � No. of Stories................ Use of Building ........ ......... ...............................
Validated By..............................................................Date ........................ Veluatio of Project: $... ....Q................................
Compensation Certificate Verified By ................. Date ........................ Owner: Pl,S7 .1{Iu.S. .P. .Sfa7f.,J.._._....._...... Phone!I.',55..s: .�
7
Contractor: '1., YVJ...!�f�d. .�e1t.I.T. City Bus. Lie. a .............. .
• • •• • $�s� Contractor's Addressf,?(�UU.S 'i,/Yns.CK. t.'✓.Q. Phone:5'aF.-5. .7
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Permit Fee (plus penalty f applicable) dzilLo Contractor - Electrical: ............._._........._.........._.....................................
Plan Check Fee (less deposit of$.......... Pct. #..........)$................. City Business License e.................... Phone:....................
Energy Plan Check Fee (Dep. of $........ Rct. #........)$................ ...... Plumbing: ......................_.._............................................................
Strong Motion Fee ..........................................................$...........!5..�.... City Business License •.............._..... Phone:....................
.............._._.............$....................... Heating and Cooling ..........._..................................................
.
Plumbing Permit Fee ................ .......... Phone:....................
City Business License •'...... ....
Electrical Permit Fee ......................................................$........--------------- Architect/Designer:
Mach. Htg./Coolg. Permit $............................. $.._................... ........._.......__......_....._.........._. Phone:....................
Residential Construction Tex ............ ................... $....................... Engineer: _.........;.........._..........._..........._._........__. Phone:....................
Mist. Fee .......$...... ..... .. Lender: . _ .. ................._...... ......................_..................... ❑ Unknown
................................................................. ... "I certifythat In the permit Is
Misc. Fee $^— .(r� Issued I shall not employ any person
of the work too which this
........................................................................
p oy y person f any manner so as to become subject
• . : $ ',� o, M to the workman' nsatlon la a of California."
SIGNATURE OF ^ I ..eAp.(
• • APPLICANT/OWNER ... _.. ... ...'.!J!�V'.W .-�......... DATE..
Environmental Status: Exempt ............ Other........................................ "I certify (hit as the applicant I am licensed unde the 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 affect: or
Cond. Use Permit #...... Variance *.... Parking Spaces............ I certry that I am exempt from the "Licensed Required" provisions of the
Approved By Date ........ Contractors License Law. (Stale basis of exemption.)
""'"""""""""""'""""""""""""""""'"' -""""""""' I hereby acknowledge that I have read this application and stale that the above Is
correct and agree to comply with all City Ordinances and Slate Laws regulating
b0dinq.
I (We) agree to save, indemnify and keep harmless the City of Cupertino
aChmeOt Permit....-..--- ............. Grant Of Easement...._.................. against liabilities, judgments,costs and expenses which may In any way
Gutter, Sidewalk, Driveway: Replace.......... Repair.......... occurs against said City onsequen eat the granting of [his per it."
.Wer............ Conn. Fee $................ Water................ Meter $................ SIGNATURE OF ,y/(p/��J��
Agreement for Completion Of PUbIIC Works Improvements .................. APPLICANT/CONTRACTOR ...... ... ^i/.!'.!�..-.................... DATE ...�Z��/
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
• • 1 120 days from validation data, or should authorized constriction be suspended or
abandoned for a period of 120 days after work Is commenced.
PERMIT.INSTALLATION NO. EACH FEE APPLICATION O,
PLUM131NO 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 .................................$4.00.. .............
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 ......- .15.00 .............. Wash. Mach..... Dishwasher.... Garb. Disp..... ................. 3.00...............
—200amp........ . 7.00 .............. Sewer ............................................................................... 8.00...............
Time Clock .................................... ................................. . 1.50............... Lawn Sprinkler Sys. $6.00 Ea. add Sys. $2.00..................... .............
Misc. (see Ord. current,...................................................... Vacuum Breakers ............................................ ..............3.50..............
New Residential Occupancies Flet Rate Interceptor........ Water Softener........ .............................4.00. ............
0-500 sq. ft. $22.00 1501-1750 $34.50............. Plumbing Piping without fixtures ............................... ....4,00................
................. Misc. (See Ord. Current) ....................................................
501-750 24.60 1751-20000 37.50.............................. Permit Fee ...................................
761-1000 26.00 2001-2260 39.60.............................. . ......................................$ 8.00
1001-1260 28.50 2261-2500 42.00.............................. •TOTAL PLUMBING PERMIT FEE (plus penalty if app. 7)) _
1251-1500 32.00 2501-2750 49.50.............................. APPLICATION FOR HEATING/COOLING PERMIf
PermitFee...............................................$6.00
TOTAL ELECTRICAL PERMIT FEE (Plus penalty If epp.p) $ PERMIT INSTALLATION I NO. EACH FEE
Forced Air Unit..................to 100M ..............................$8.00...............
INSPECTION RECORD over 100M .......................... 10.00.. ...........
.to 3 ton/HP ........................
.
.
.
. ... 6.00... ...........
Forme / Foundation .............. ......... . . BY:........ . ..... . Date:. ..........._.. Comfort Cooling Unit. to 15 ton/HP......................... 9.50..............
Plumbing Ground Work . .................... ...........................................
Rough Electrical .................................... ...:..........................I..................... to 30 ton/HP...........................12.00. ............
to 50
e - plumbing and Heating Heater n/HP...........................17.00.. ...........
........................................................ Space Heater........ Wall Heater ................................... a.g011111r ..............
tion & Energy............................... ......I............................................. Flues - other than above ............................................... 3.00..............
F
Test ................................... ....... ......................... ......................... Vent Fan: Kitchen........ Bath ......................................... 3.00...............
emporary Power Gas / Elect. ............................................................ Commercial Range Hood „ 6.00,,,,__.,,,,,,,,
..........................................l
Final - Electrical ............................................................. ........................... Misc. (Sea Ord. Current..................................................,............. ............
Final - Building/ Mechanical .................................................................. Permit Fee ........................................................................ $ 6.00
Final - Design Review / Landscaping . ..... ....._...................._.. TOTAL Htg./ Coolg. Permit Fee (plus penalty if app. 7]) $
Final–Public Works ...........................................................