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2122J CITY OF CUPERTINO APPLICATION FOR RESIDENTIAL BUILDING PERMIT AND CERTIFICATE OF OCCUPANCY BUILDING INSPECTION DIVISION CITY OF CUPERTINO • ''•I -H 1 1 I PERMIT NUMBER I c,2/a-Z DEPARTMENT USE ONLY PlansReceived By .................................................... Date ......................... REO.: Plans.... Survey.... Calcs: Struc..... Energy.... Elect..... Mach.... Plans Checked By ................ .. Date ... ......................... Application Approved B ......................... Data ValidatedBy............................................................. Date ........................ Compensation Certificate Verified By .................. Date ............ .-......... Permit Fee (plus penalty if applicable) .............1/r Plan Check Fee (less deposit of $.......... Rct. #.... -...) $....., ---r.. Energy Plan Check Fee (Dep. of $........ Rct. #........) $.......:.............. Strong Motion Fee ............. ......... -........ .................. .... -- $.......... ._,I7.... Plumbing Permit Fee .- ................. --- .... ............ -$...... ....... ....... Electrical Permit Fee .......... -............. - ............... -.... - $........... ._........ Mach. Htg./Coolg. Permit $............................. $....................... Residential Construction Tax ........ ...................- $.... ....... .......... . Misc. Fee ...... ............... ... -.................. - ............. _.... $......... ..._........ Misc. Fee .. ..... --..... ............................. ....... .............. --- $.............. ...... - ,III ZONING ! 3.50 .. __........ Environmental Status: Exempt ............ Other ....... .................... - ....... .... Design Review Approval: Bldg ...... _._.. Site ... ..... _.. Sign ........ Use Zone ............ P.D. Conditions ... ........................... ................. --..... Cond. Use Permit #............ Variance #.--.-...... Parking Spaces............ ApprovedBY ........................ -- ... ...... ..................... Date ................ --- ...... WORKSPUBLIC r croachment Permit ........................ Grant of Easement........................ rb, Gutter, Sidewalk, Driveway: Replace ...... Repair.......... Sewer............ Conn. Fee $... -.......... Water ................ Meter $ ................ Agreement for Completion of Public Works Improvements .................. Plans Checked By........ Date........ Approved By........ Date .................... PERMIT INSTALLATION NO. EACHFEE Light f(/V• Outlets... ___ ... Switches.........7MWvr '�'sl4 1.00............... Fixtures............ Receptacles............ yyam�// 4.00............... Water Closet.... Water Heater.... Ld. Tray ..................... TOTAL NUMBER (less than 100 w-aT[s) ..... ...... $ .50 Range........ Cooking Unit____ Oven ..................... .._... 2.00 ........ Dryer........ Garb. Disp......... Dishwasher .................... Lawn Sprinkler Sys. $5.00 Ea. add Sys. $2.00........... 2.00 .............. MOTORS: 1 HP or less . .......... ............ ._........... ......... 2.00 .. .....__... Greater than 1 HP not more than 5 HP ............... Plumbing Piping without fixtures ...................................4.00............... 3.50 .. __........ Temporary Power Pole or Service — 100 amp .........5.00 $ 6.00 _._.... — 200 amp ......... 7.00 .............. TimeClock ........... ............. . ....... ..........._.. ...._... 1.50 ... ........... Misc. (seen e Ord. current ) ...................4 New Residtial Occu panties Flat Rate 0-500 sq. ft. $22.00 1501-1750 $34.50 .............................. 501-750 24.50 1751-20000 37.50 .............................. 751-1000 26.00 2001-225C 39.50 .............................. 1001-1250 28.50 2251-2500 42.00 .............................. 1251-1500 32.00 2501-2750 49.50 .............................. Permit Fee...............................................$6.00 TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.C) $ Forms / Foundation ....... .................. I By:.. _.... ... ... Date:................ Plumbing Ground Work ......... I ..... ................ .._................ _..... RoughElectrical ............. ....................._. ........................... me - Plumbing and Heating..........1........................ ulation& Energy ................. ........... ..__................_.. .............._.......... WE Test Temporary Power Gas /Elect. ......_ __.........:........._-...........--......... Final - Electrical ...................... ............_....__... ....... .... ........... .._............ Final - Building / Mechanical .......... .................... Final - Design Review t Landscaping ..... ..._...... _........ ............._...... Final - Public Works........................................................... S ADDRW OF PR J T: Legal Description: Tract ........................ Block ......... Lot...................... Description of Work: ._/N.TG!eC °!i...._0-,. ...,BAJ.-v-M..:P.C.7- ..... Q. . f -x .................. ............................. ..........................--................. 1st Structll mprovement on Parcel: Yes.... No... Area of Bldg ............... Separate Structure............ or Addition/Alteration to Exist. Bldg........... No. of Stories ................ Use Of But ...... ---- ... .......... .................... Valuation of,P of gt:. $ ..._. A.O. .a ..._..........v. J.q Owner: t./ef(.L.L(_;.. ...... _._... L.�1... �..... PhonEc,!Z..�-l.l. `.( Contractor: ..... ........... _.............. _._................. City Bus. Lic. #-............ Contractor's Address: .... ......... : ...... _- ................. Phone:.................... Contractor - Electrical: . . ................. - ........... .... ........ -- .................. City Business License #..........._..__. Phone:..... ............. Plumbing: ......... ....................... . ................. --................. City Business License #.................... Phone:.................... Heating and Cooling ...... ....................... City Business License #............ .... Phone:... ................ Architect/Designer: ....... ................. ..... .,,, Phone:.................... Engineer: . ........ ............. - ....................... Phone:_ Lender:. _........ ...... ... .... .... .... ...._............ .... ......... .... .. ❑ Unknown .. "I certify that in the performance of the work for which this permit Is issued I shall not employ any person in any manner so as to become subject to the workman's c�om^pe'nsatia laws of Cil if•Orni�a." yI 51U APPLAIUMt OF IICANT/OWNERYA.Iv"!��'..r.I,..... ... DATE . .... "I certify that as the applicant I am licensed unde' the provisions of the Contractors License Law and further that my Licens. No ............................. in Classification ....................... _........... is in full force and effect: or . .. I certify that I am exempt from the "Licensed Required" provisions of the Contractors License Law. (State basis of exemption.) I hereby 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. I (We) agree to save• indemnify and keep harmless the City of Cupertino against liabilities• judgments, costs and expenses which may in any way secure against said City in consequence of the granting of this permit.'' SIGNATURE OF APPLICANT/CONTRACTOR .........._........................................... 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 120 days from validation date, or should authorized constrnctlon be suspended or abandoned for a period of 120 days after work is commenced. A. PERMIT INSTALLATION N0. EACH tit Gas System with up to 5 outlets .................................$4.00. ............. Each additional outlet ............................................. 1.00............... Water System (Installation, Alt. or Repair) ....... .......... 4.00............... Water Closet.... Water Heater.... Ld. Tray ..................... 4.00.............. Lavatory.... Shower Pan.... Bathtub.... Sink... .... . ........ .. 3.00............... Wash. Mach..... Dishwasher.... Garb. Disp.................... 3.00............... Sewer....-- .................... --........ -._ ...................... ........ . - 9.00............... Lawn Sprinkler Sys. $5.00 Ea. add Sys. $2.00........... ............. Vacuum Breakers ............................................ ..............3.50.............. 3.00............... Interceptor........ Water Softener.... .................................4.00. ............ Plumbing Piping without fixtures ...................................4.00............... ............ Misc. (See Ord. Current) .................................................... $ 6.00 PermitFee.......................................................................... $ 6.00 TOTAL PLUMBING PERMIT FEE (plus penalty if app. ❑) $ PERMIT INSTALLATION NO. I EACH I FEE Forced Air Unit .................. to 100M ..................... .........$ 6.00,.............. over 100M ......................... 10.00 ............. Comfort Cooling Unit..... to 3 tort ........................... 6.00............... to 15 ton/HP ......................... 9.50.............. to 30 ton/ HP ........................... 12.00 ............. to 50 ton/HP ........-- .............. 17.00 .. ........... Space Heater........ Wall Heater ................................... 6.00.............. Flues - other than above ... ...... -......................... ........ .I.. 3.00.............. Vent Fan: Kitchen........ Bath ...... ..................... .... ........`.. 3.00............... .................................... Commercial Range Hood ......... 6.00,,,,,,,,,,,,,,, li Misc. (See Ord. Current .............. .................. ..--111...... .................. ............ PermitFee ..........................-....-............-..................... $ 6.00 TOTAL Htg./ Coolg. Permit Fee (plus penalty if app. ❑) $