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11750 CITY OF CUPERTINO APPLICATION FOR RESIDENTIAL BUILDING PERMIT AND CERTIFICATE OF OCCUPANCY 1b BUILDING INSPECTION DIVISION Plans Received By ...........11-1.77 ............... .............. ...... Date...Y �/E ... Pll Plans.... Survey.... Calc tuc..... Energy.... E,Be...... so Plans Checked 8'UDate .... Application Approved By Validated By ..... * _ -'*'* -------- - Date .................. Compensation Certificate Verified By ................. Date ......................... Permit Fee (plus penalty it applicable) .... .................. Plan Check Fee (less deposit of $.......... R C I., #.v ........ I $ ....................... Energy Plan Check Fee ....... ............ Strong Motion Fee ....................................... n.......... $........._!.....:..... Plumbing Permit Fee ......... $ Electrical Permit Fee .................................................. 10 ..... --- g.e-!Pjq.. Mach. Htg./Coog. Permit $ ..................... .... $ ....................... Residential Construction Tax .... f:. .; ... .... _$ ....................... Misc. Fee .......... . I ................................ •......... I................. $....................... Misc. Fee ................................... ................................... Environmental Status: Exempt ............ Other ........................................ Design Review Approval: Bldg ............. Site ............ Sign ............ Use Zone ........tete P.D. Conditions ............................................................ Cond. Use Permit #............ Variance # ... __ ..... Parking Spaces............ ApprovedBy ............................... ....... Date ........................... • croachment Permit ........................ Grant of Easement........................ rb, Gutter, Sidewalk, Driveway: Replace.......... Repair.......... war............ Conn. Fee $ ................ Water................ Meter $................ Agreement for Completion of Public Works Improvements .................. Plans Checked By........ Date........ Approved By........ Date .................... PERMIT INSTALLATION NO. EACH FEE Light Outlets .... Z.� Switch,s..L- 761-1000 26.00 2001-225C Fixtures ............ Receptacles............ 2�� .............................. 1001-1250 _0 TOTAL NUMBER (less than 1000 watts) ... 42.00 $ .60 1261-1500 Range........ Cooking Unit........ Oven.........._ ................ 2501-2760 2.00 .............. .............................. Dryer........ Garb. Disp ......... Dishwasher .................... PermitFee 2.00 .............. MOTORS: I HP or less ...... _ .. ............................. 6.00 2.00 - ...__.. Greater than 1 HP not more than 5 HP .__ 3.50 .. ......... _ Temporary Power Pole or Service 100 amp . . ..... .. 5.00 .............. 200 amp . ..... _ , 7.00 TimeClock ....... ................ _ ... ......... ................ ....... l.. 1.50 ... ......... .. Misc. (see Ord. current ) ...................................................... New Residential Occupancies Flat Rate D-500 sq. ft. $22.00 1501-1750 $34.50 601-750 24.50 1751--20000 37.60 .............................. 761-1000 26.00 2001-225C 39.50 .............................. 1001-1250 26.50 2251-2500 42.00 .............................. 1261-1500 32.00 2501-2760 49.50 .............................. Plumbing Piping without fixtures ...................................4.00............... PermitFee ...............................................$6.00 PermitFee .......................................................................... $ TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.]) $ 6`4 9 ✓ Forms / Foundation .1=�Vr offld By:.Il Date:?.�Z-W Plumbing Ground Work Rough Electrical ' ............. gJaLrame - Plumbing anclHeiting ............. J I at I on 1, Energy ....... ............. Test............... ......... .................... am porary Power EleOt .. ...............................1__....._................. ............. Final - Electrical . ..... I ............ ................ Final - Building / I .............. ... ... Final - Design Review . ....... Final - Public Works... ............................. ** ......... ► 0 PERMIT NUMBER I 117S - TOR S V .. M!�ADPPA _-P .__Dig...._._ ... ............................... Legal Description: Tract ................. Block............ Lot...................... Do/criptlon ,�q, work: 4:4.Q ...... ..................................... ........ 1st mprovement on Parcel: Yes.... No.... Area of Bldg.... ........... Separate Structure............ or Adjtti Alteration to Exist. BI 9 . ... .... No. of Stories........... Use of Building ..... ............. Valuation of Projecl:rj I ��/ -?.� ...... .. ................. ............ Owner: L -M -4M T. i-- C>.........................Phone:7�91-7 Contractor: 6.0 ........ City Bus. Lic . .. ........... Contractor's Address: 1 Contractor - Electrical: ....... City Business License .................. Phone:.................... Plumbing: ... .......... ................ __ ............................... City Business License # .................... Phone:.................... Heating and Cooling .. ... ..................... _ ..... ................ ....... City Business License .................. Phone:.................... Architect/ Designer: Phone:.9.__0/(,,,,(Z. Engineer:....� . .. ........ . ................ .................. Phone:.................... Lender: ..... .... . ....... ..... .......... in w "I certify that In thed f the work for whIcIN"this theral issued I shall not Sm_-R-� 'noyCrman.c.o. of the mmrb?, so as to become subject in k at fin a. for to a workman's •rp a a we 1 SIGNATURE OF APPLICANVOWNER' DATE..�./L_/.b/ rI.b,.,nf at as tth A�Z.Dlcant I am licensed unde the provisions Of the , actors License Law and further that my License 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 [a correct and agree to comply with nil City Ordinances and State Laws regulating building. I I (We) agree to save, Indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and a hich Ing way , . p es 'c y I. secure against said City I�nrn �.e t g Ung may thrift." SIGNATURE OF APPLICANT/COIx )R 01- ifin 'D ... ............... ')R ..... DATE 4 at NOTE: When p d1dat.cl this form constitution, 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 construiellon be suspended of abandoned for a period of 120 days after work is commenced. Use System With Up to 5 Outlets .. . .............. ........ .. $4.00 . ............. Each additional outlet ... __ ...................... ........ .. 1.00 . ............. Water System (installation, Alt. or Repair) ....... ........ .. 4.00 . ............. Water Closet.... Water Floater.... Ld. Tray ........... ... ... .. 4.00 . ............. Lavatory.... Shower Pan.... Bathtub.... Sink ......... ........ .. 3.00 . ......... Wash. Mach..._ Dishwasher.... Garb. Disp ..... ..... ........ .. 3.00 . ............. Sewer...... ... ___ .......... _ ....... ...... _ ..... _ .......... ........ .. 8.00.. ............. Lawn Sprinkler Sys. $5.00 Ea. add Sys. $2.00 ..................... ............. Vacuum Breakers ............................................ ..............3.50.......... tete Interceptor........ Water Softener ........ _ .............. ....4.00............. 6:000 :::::� [ Plumbing Piping without fixtures ...................................4.00............... Misc. (See Ord. Current) ........................ PermitFee .......................................................................... $ 6.00 TOTAL PLUMBING PERMIT FEE (plus penalty If app. rl) S Forced Air Unit .................. to 100M ...... .............. ....... .$6.0o ... ............ over 100M .........................10.00 .............. Comfort Cooling Unit...... to 3 ton/HP ................. ........ .. 6.00 ... ............ to 15 tort ......................... 9.50 .. ............ to 30 ton/HP................. .. .... I - ..12.00 ............. toy ton/HP ................. ........ ..17.00 ... ........... Space Heater........ Well Healey .... ....... 6.00 .............. Flues - other than above ..................................... 3.00.. ......... Vent Fan: Kitchen........ Bath ............. ........ ........ . * ':-- ---- Commercial Range Hood ............... .............. 6:000 :::::� [ Misc. (See Ord. Current ... _ ................ .................. I ........ ......... J ... ........ Permit Fee ............. ... ............. .............................. ..... $ 6.00 TOTAL Htg,/ Coolg. Permit Fee (plus penalty if app. 0) $