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1572CITY OF CUPERTINO t APPLICATION FOR RESIDENTIAL BUILDING PERMIT AND i-- Ct,'.•o". CERTIFICATE OK4dCCUPAf4FCYJ BUILDING INSPECTION DIVISION PlansReceived By .................................................... Date ......................... REQ.: Plans.... Survey.... Calcs: Struc..... Energy.... Elect..... Mach.... PlansChecked By _......_._ .......................................... Date ......................... Application Approved By .................. ..... Date ........ --- ........... Validated By ....... ......... ... .. .... Date ............... Compensation Certificate Verified By .... Date ........... 'VALUATION OF PROJECT Permit Fee (plus penalty if applicable) - ..................... $.. 24....Q.O....... Plan Check Fee (less deposit of $.......... Rct. #..........) $.- .................... Energy Plan Check Fee (Dep. of $........ Rct. #........) $....................... Strong Motion Fee ........................... .....--- ............... - $...........5.0....... Plumbing Permit Fee ................................................ $-.................... Electrical Permit Fee _._ ....................... - ... ... ................ $... ----- - Mach. Htg./Coolg. Permit $............................. $....................... Residential Construction Tax ............ ................... $------------- ....._.. Misc. Fee ............................................. .p..�..k..... Misc. Fee ............... ................. $.............q.....�... $...... $ 30.50 ZONING REQUIREMENTS Environmental Status: Exempt ............ Other ............... ................. Design Review Approval: Bldg ............. Site ............ Sign ............ Use Zone ............ P.D. Conditions ............... -- ........... - ..... .............. -- Cond. Use Permit #..... _..... Variance #............ Parking Spaces............ ApprovedBy .................. _...... ....... ........ _......... Date ... ._.................... roachment Permit. Grant of Easement ..... ..._.............. rb, Gutter, Sidewalk, Driveway: Replace.......... Repair..... -- ....Sewer............ Sewer ............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............ Switches............ Fixtures............ Receptacles............ TOTAL NUMBER (less than 1000 watts) ............ $ .5o . ........... Range........ Cooking Unit........ Oven._....__...._ .... ...... . 2.00 .. ........ -- Dryer........ Garb. Disp..... :... Dishwasher ............. ...... 2.00 -............ MOTORS: 1 HP or less ................ .... - ....... ........... .. ..... 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...................................................................... 1.50............... Misc (see Ord. 2urrent5.............................. .................... n New Residential Occupacies Flat Rate 0-500 sq, ft. $22.00 1501-1750 $34.50 .............................. 501-750 24.60 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.p) $ Forms / Foundation ......... .............. _ By:- ... ,.. ........ Date:............... Plumbing Ground Work ..._......... ..... _ . ..... ....... . ........ -- .... ......... Rough Electrical ...... --- ....-- ....... ......... :.. ........ ........ - .................. Aftrne - Plumbing and Heating..........1._........_....... .......__........_.......... dation& Energy.,.. ............................._................_. ._...... _................ GasTest .._..........._.... I .... ...... ...... ....-..... ............. h Temporary Power Gas / Elect. . ...... ..._.- ..............._I .................... Final- Electrical ...... ..... _.--.... ..... --...._...................... ................. Final - Building / Mechanical ....................................... ........................... Final - Design Review / Landscaping ..- ..................... -a ................. Final - Public Works........................................................... PERMIT NUMBER ,. APPLICANT STREET ADDRESS OF PROJECT: .............14 9.1... Pr.ingr o.s e..Wa.y............................................................. Legal Description: Tract........................ Block........... Lot ................. Description of Work: 2. ... yr....Woodla..nd..,sh Agles.... app ... i .......over- exist.ing...wood..shingle...roof..._....................... 1st Struct. Improvement on Parcel: Yes_ _ No... Area of Bldg ............... Separate Structure............ or Addition/Alteration to Exist. Bldg........... No. of Stories ........ 1 ... - Use of Building _......residence ................. Valuation of Project $2,895 00 _, ._ _ ...., ...................... Owner:. .Mx O P,!]one-2527.2012 h lI IR Contractor: Zava a. 00 1 g Co � B LIc # - '• //GG Contractor's Adtlress:.740... .. San._�ar os Phone:28bam XX}kX3MXXE€&X#W- .-San-Jose,.. Ca...........9512.................... 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 note loy any pe????rssyon in any manner so as to became subject to the workman's en sation l f Californ SIGNATURE OF (/,• 11-3_80 APPLICANT/OWNER ...... l ... ............_.... Ln.......... DATE........................ y .... "I Contractors t .l a the applicant am that etl untle the pr v' ops the in Classification mrs License Lave, AnA rlher that m Licforc No. Sect: .r ....... in Classilication ....... ....._. ,,,, ,,,,_,__. is in lull lane 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 beifdmg. 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.' SIGNATURF 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 construction be suspended or abandoned for a period of 120 days after work is commenced. APPLICATION•• PLUMBING PERMIT PERMIT INSTALLATION NO. EACH FEE 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............................................................................... 8.00............... Lawn Sprinkler Sys. $5.00 Ea. add Sys. $2.00 ..................... ............. Vacuum Breakers .... -...................................... ..............3.50.............. Interceptor........ Water Softener.....................................4.00............. Plumbing Piping without fixtures ............................... ....4.00,,,,,,-........ Misc. (See Ord. Current) .................................................... PermitFee..........................................................................$ 6.00 TOTAL PLUMBING PERMIT FEE (plus penalty if app. Cj) $ APPLICATION••HEATING/COOLING PERMIT INSTALLATION NO. EACH FEE Forced Air Unit .................. to 100M ..............................$ 6.00............... over100M ......................... 10.00 ............. Comfort Cooling Unit...... to 3 torl ... .......... :... ........ .. 6.00............... to 15 ton / H P ........- ............. 9.50 .............. to 30 torl ............ - ... ...... - - 12.00 ............. to 50 ton/HP ........................... 17.00.. ........... Space Heater........ Wall Heater ............. - ........... ........ 6.00.............. Flues - other than above ............................................. . 3.00.............. Vent Fan: Kitchen........ Bath ..................-................. .. 3.00............... Commercial Range Hood..............., 6.00,,,,,,,,,,,,,,, Misc. (See Ord. Current..... ..............._......._................. .... .......... ............ PermitFee ................................. ................................. -.... $ 6.00 TOTAL Htg,/ Coolg. Permit Fee (plus penalty if app. ❑) $ •. z Sheet 2" CITY OF CUPERTINO BUILDING PERMIT Permit No: Job Address: 1491 Primrose Way Date: 11-3-80 BUILDING PROJECT IDENTIFICATION Applicant's Mailing Address 740 W. San Carlos St, San osP_ Ca 95126 Address of Building Owner's name Telephone No. ✓ Contractor's Name Contractor's Mailing Address 1491 Primrose Way Zavala Roofing Co., Inc. 740 W_ San CnrTOs St. Sar, .Tnso CA 95126 Lic. No. C.19--19411922 Architect or Engineer Architect's or Engineer's Address Lic. No. LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and n6icense is in full force and effect. 384892 License Cl a ..SS 77 Lic. Number Date 1- - Contractor Zavala Roofing OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License •Law for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty OF not more than five hundred dollars ($.300).): ❑ 1, as owner of the property, or my employees with mages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improvements are not ini ended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he did not build or improve for the purpose of sale.). ❑ 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License lase does not apply to an owner of properly who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law.). ❑ 1 am exempt under Sec. , B.&P.C. for this reason Dale. Owner WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self -insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Ser SW, _ab.C.�. Policy No. Company Certified copy is hereby furnished. Certified copy is filed with the county building inspection Apar�jrrppen�� or �qppunty r t, Date J, L8ytpplicant �e aura°tt ofin Co. Inc. CERTIFICATE OF EXn. IPTION FX( . I WORKERS' COMPENSATION INSUR. NCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, l shall not employ any person in ane manner so as to become subject to the Workers' Compensation,Laws of California. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. Co. , Inc. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the Performance of the work for which this permit.is issued (Sec. 3097, Civ.C.). Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this county to enter upon the above-mentioned property for inspection purposes. Signature of Applicant or Agent Dare "OWNER -BUILDER VERIFICATION "Attention Property Owner: "An'owner-builder' building permit has been applied for in your name and bearing your signature. -Please Complete and return this information in the envelope provided at your earliest opportunity to avoid unnecessary delay fn processing and issuing your budding permit No building permit will be issued until this verification fs received. 1. 1 personally plan to provide the major labor and materials for Construction of the proposed properly improvement (yes or no) 2 1 (have/have not) signed an application for a building permit for the proposed work 3. I have Contracted with the following person (firm) to provide the proposed construction: Name Address City Phone Contractors License No. 4. 1 plan to provide portions of the work, but 1 have hired the following person to coordinate, supervise, and provide the major work- Name Address City Phone Contractors License No. 5. I will provide some of the work but I have contracted (hired) the following persons to provide the work indicated: Name Address Phone . Type of Work Signed: Property owner Social Security number _ Date: