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1192 0 CITY OF CUPERTINOPERMIT NUMBER APPLICATION FOR RESIDENTIAL BUILDING PERMIT AND FOR , , TO CERTIFICATE AND OCCUPANCY FILL IN BUILDING INSPECTION DIVISION ST E T.AD9REF OF PROJECT: 10 O Y�'�:�.TGr�S.....!<IA.7�+.fi...�oT..,MM��✓..... DEPARTMENT USE ONLY Legal Description: Tract....................... Black............ Lot...................... Plans Received By... Description of Work: .f A—r..L.0.... ,0.u.#,Nn..........._._............... y....................................................Date ......................... .....Stru..........p......._......................al:..........._.._..._A.r, ........B.I.................... REO.: Plena.... Survey.... Celca: Strut..... Energy.... Elect..... Mach.... �1 st Strutt. Improvement on Parcel: Yes._.. No... Area of 81dg............... Plane Checked By....................................................Date ......................... Separate Structure.:.......... or Addition/Alteration to Exist. Bldg AApplication Approved B P g........... PP PP Y.........................................Date ..........---............ . No. of Stories................ Use i Buildin g .................. ............................... Validated By..............................................................Date ........................ Valuation of Project: $.../................ ........................... Compensation Certificate Verified By .................. Date ............ ............. Owner. .SA.,t,[C„_.. _a..�.! A!�'J1•........ Phone:,2s'S:.r � .Yr Contractor: ...... ........_.... ... .......... ........ .....City Bus. Lic. * .............. • • • • $ Contractor's Address: ..............................__............ Phone:.................... Permit Fee (plus penalty If applicable) _ Contractor - Electrical: ......_............._.........._.._....................................... Plan Check Fee (less deposit of$.......... Rol. #.........J$.....x,�""��"� City Business License *............_..... Phone:.................... Plumbing: . Energy Plan Check Fee (Dep. of $...,..-LRgtC#........) $............... . . ... .................................._........................ Strong Motion Fee ..........._...C,�Y. .r:.tit.................._..$......._1 City Business License *........._......... Phone:.................... Heating and Cooling .......................................... Plumbing Permit Fee ................1.. $...................... _....................... Mach. Ht /Cool Permit $... 1 n 4..�y {1'..........$.... - City Business License *.................... Phone:.................... Electrical Permit Fee .............. ll.�..H,. Architect/Designer: ... ........._... ..._........._..._......... Phone:.................... 9. g. �..............:........... $................. Engineer: . . ...._ . _................................................. Phone:.................... Residential Construction Tax .................... .... . $....................... Lender: . .. . .... ...... .. ... .... ........................................_.. ❑ Unknown Misc. Fee -y...!k �........ $. otv .................................... ........................ '--" �.. "I carol That in the Mise, Fee ......................: $..... - y y rformanceany person of the work for which thiseco a rmitsubject le ""�""""�' �""""-�"-""""��"""" "'���'-'-�-��� certify I shall not employ any person in any manner so as to become eublecl s . $ �.�� to the workman ompensatlon I➢we of California." SIGNATURE OF /'/� �y �) • • APPLICANT/OWN ... ... .._.. ._G^+`� "'... GATE.- c�..10� O Environmental Status: Exempt............ Other............ _............... .,. •'I cmbl Thal s the applicant I am licensed unde the provisions of the Design Review Approval: Bldg. ............ Site ............ Sign .._........ Coal :or icense Law and further that my Licens, No. ........ ....__............ Use Zone ............ P.D. Conditions .................................. . ............... in Classification ........ .......................... is In full force and effect: or Cond. Use Permit a............ Variance *............ Parking Spaces............ - I certify that I am exempt from the "Licensed Required" provisions of the Contractors License Law. (Slate basis of exemption.) Approved By......................._........................_..._... Date .._....................... I hereby acknowledge that I have read this application and state that the above Is s . s :orrecl and agree to comply with all City ordinance, and State Laws regulating • builtlmg. I (We) agree to save, Indemnify and keep harmless the City of Cupertino croachment Permit........................ Grant of Easement........................ against liabilities, judgments, costa and expanses which may In any way rb, Gutter, Sidewalk, Driveway: Replace.......... Repair.......... acture against said City in consequence of the granting at this permit." ewer............ Conn. Fee $................ Water................ Meter $................ SIGNATURF 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 veld should work not be commenced within • • 120 days from validation date, or should authorized construction be suspended or abandoned for a period of 120 days eller work Is commenced. PERMIT INSTALLATION NO. EACH FEE Light Outlets............ Switches............ I I APPLICATION • • PLUMBING 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 ........ ..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..................I.... ............. Mise. (see Ord. current)...................................................... Vacuum Breakers ........................................... ..............3.50............. . Now Residential Occupancies Flat Rate Interceptor........ Water Softener........ ..... ............4.00. ............ 0-500 sq. ft. $22.00 1501-1750 $34.50.............................. Plumbing Piping without fixtures ...................................4.00-.............. Mist. (See Ord. Current) ..........................................6.00**­ 601-750 24.60 1751-20000 37.50.............................. Permit Fee ........................ 751-1000 26.00 2001-225C 39.50.............. .....................ally...................$ 8.00 """'•"""" TOTAL PLUMBING PERMIT FEE (plus snail 1001-1250 20.60 2251-2500 42.00.............................. penalty If app. [J) $ 1251-150032.00 2501-2750 49.50.............................. APPLICATION - HEATING/COOLING PermitFee...............................................$6.00 TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.0) $, PERMIT INSTALLATION IIIN0. EACH FEE Forced Air Unit..................to 100M ............. ......--.........$ 6.00............... • " ' over 100M ....................... . 10.00.. ........... Forms / Foundation .......... .... .............. By:....._. . .._. . Date:................ Comfort Cooling Unit......to 3 ton/HP ........................... 6.00... ........... to 15 ton/HP......................... 9.50.............. Plumbing Ground Work . _.................. L.... .._............ ................... ....... to 30 ton/HP......................... .. 12.00. . . ........... Rough Electrical .................................... ........................ ........................... to 50 ton/HP........................... 17.00.. ........... •rame - Plumbing and Heating .........L....................... .................._....... B.00 ulatlon &,Ener ................. S 3C0 Heater..han Wall Heater .................................. .............. 9 ......._.... ..._.._............. ........................... Flues - other than above .............................................�. 3.00.............. s Test ..........................._...... ..... .._.. . ...... ._.....'.................._:._.. Vent Fan: Kitchen........ Bath .......................................`.. 3.00............... Temporary Power Gas / Elect. _...... ..._..._........_..... __..__._..._........ Commercial Range Hood `, 6.00... Final - Electrical ............... . . . 9 .............._..........................`.. ............ . . . . ....................................... ........................... Misc. (See Ord. Current........._............................................... ................. Final - Building/ Mechanical .................................................................. Permit Fee .... $ 6.00 Final - Design Review / Landscaping . ... ........._................._............ TOTAL Htg./ Coolg. Permit Fee (plus penalty if app. I-]) $ Final- Public Works ...........................................................