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1584 CITY OF CUPERTINO 011 6:nHo APPLICATION FOR RESIDENTIAL BUILDING PERMIT PERMIT NUMBER AND 1VU� FOR APPLICANT TO FILL IN CERTIFICATE AND OCCUPANCY BUILDING INSPECTION DIVISION ,1STREEt[1ADDRESkOF P,RQJECT: ....... ....... ............ .j.--/OF/LPRPJECT .............. • • • - . Legal Description: Tract.... Bio ck.. ......... Lot...... ............... .... . _-__ Plans Received BY....................................................Date ......................... -Description of Work: .S..aA?.e. ..._W4066- ..Lit'._...... REO.: Plans.... Survey.... Calcs: Struc..... �pergy.... Elect..... Mach.... 1st Struct. Improvement on Parcel: Yes.... No...Area of Bldg............... Plans Checked By.........................(/�../.7......'-.7.........Date ... /. .. /n1 Separate Structure.....:,:.... or Addition/Alteration t9 Exist Bldg... ....... Application Approved By. ..._...r........Date .rtes.../ V No. of Stories.....2,. Use of Buildi .•6.e'.o.;2lQ.... CLin1��/9...... Validated By..............................................................Date ........................ Valuation o Prof ct: $.... .,2-.7,3.. .. § ................ ..................... ............... Compensation Certificate Verified By ._.............. Date ......................... Owner: .JoGLC.. ._.. .. . ... .................. Phone:72,&SLS.. • • • Contrty Bus. Lic. * .............. $ Contractor's Atldress: Permit Fee (plus penalty If applicable) $..! ....:.. Contractor - Electrical: _.................. .............. .. ................._......... (P P Y PP ) ...._......._........ Plan Check Fee (less deposit of $._._._. Rct. #........_)$.._l.0'7.:..d[G. City Business License *Li �r .. Phone:.................... Energy Plan Check Fee (Dep. of $........ Rct. #........) $................. Plumbing: ...-.................................................................................. City Business License *.................... Phone:.................... Strong Motion Fee ........................................._........__...$...........! . ..0.. Heating and Cooling ...........__._.............__.......................... ... Plumbing Permit Fee .................... .............. $_J.V_d _. City Business License *.................... Phone:........­......... Electrical Permit Fee .................... ....__................._ $......... Architect/Designer.-----�-� �- Mach. Htg./Coolg. Permit $............................. $ ... ....._...._...................... Phone:.................... Residential Construction Tax ..........__..................__...$.... -ender: .: . . . ......-.._.................. ........................._... Phone:........._.._.... .. Lender: ........ ..._. ... ._ .... .........._.................. ...__....... ❑ Unknown Misc. Fee ............ ............................... $._... ..... "I certify that in the performance of the work for which this permit Is Misc. Fee .................. ............................... ..._........_...... .................�.�..}� issued I shall not employ any person in any manner so as to become subject nmnn • . , , ; $ 0,(w to the workman's comp ns tion laws of California." SIGNATURE OF • - • APPLICANT/OWNER .. .. _._.._...., ......... DATE_rr3fJ.O Environmental Status: Exempt ...___ Other...__........ ................. .."I eartily that as the applicant I amlicensed unde the provisions oJ1he S Design Review Approval: Bldg. . . .... Site Sign ........... contractors License Law and further that my Ulcers. Use Zone P.D. Conditions in Classification ._G-.�.Q.... ............ is in full force and effect: or ......rmi .......................arks............ccs............ Cond. Use Permit *........ Variance *............ Parking Spaces...... I certify that I am exempt from the "Licensed Required" provisions or the ,. Contractors License Law, (State basis of exemption.) Approved By..............................................__..._._ Date ........_................. 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 WORKSIN PUBLIC • budding. I (We) agree to save, indemnify and keep harmless the City of Cupertino lawer h in Permit...................._.. Grant Of Easement........................ against liabilities, judgments, costs and expenses which may in any way utter, Sidewalk, Driveway: Replace.......... Repair.......... acture against said City in c s Lienee of the granting of this permit:' ......... Conn. Fee $................ Water................ Meter $............ SIGNATURE OF Agreement for Completion of Public Works Improvements ............_.... APPLICANT/CONTRAc7o ..... .. ........ .... DATE ///,3 .U..0 Plans Checked By........ Date........ Approved By........ Date.................... NOTE: when properly validated this form constitutes a Building .H. This permit expires and becomes null and void should work not.be commenced within APPLICATION • . ELECTRICAL PERMIT 120 days from validation date, or should authorized consWction be suspended of assiss abandoned for a period of 120 days after work is commenced. PERMIT INSTALLATION NO. EACH FEE APPLICATION • • PLUMBING 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 .. ...Q .. Water System (Installation, Alt. or Repair) ................. 4.00......!'fl MOTORS: 1 HP or less ........................................ ..�.... 2.00 .�.A0 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 ..I............ Wash. Mach..... Dishwasher.... Garb. Disp..... ............... 3.00,.............. —200 amp.... .... 7.00 ........... Sewer .... ................__..........................-......................... 8.00............... Time Clock .................................... ..._.............._....�... . 1.50.....1x5_ .. .0 Lawn Sprinkler Sys. $5.00 Ea. add Sys. $2.00..................... ............. Mise (see Ord. current 1.... ................................................. Vacuum Breakers ............................................ ..............3.50.............. New Residential Occupancies Flat Rate Interceptor........ Water Softener........ .............................4.00. ............ Plumbing Piping without fixtures ......... . ....................4.00. .....i� . .... 0-500 sq. ft. $22.00 1501-1750 $34.50.............................. Mise. (See Ord. Current) .$(6.4t5td•L .......x1.?0...: JIM • 501-750 24.50 1751-20000 37.50.............................. Permit Fee ..........................................................................$6.0 751-1000 26.00 2001-2250 39.50.............................. TOTAL PLUMBING PERMIT FEE (plus penalty if app. Q) $ .Ofl 1001-1250 28.50 2251-2500 42.00.............................. 1251-1500 32.00 2501-2750 49.50.............................. APPLICATION FOR HEATING/COOLING PERMIT PermitFee...............................................$6.00 TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.p) $p PERMIT INSTALLATION NO. EACH FEE / Forced Air Unit.........._.....to 100M .._................. - -$ 6.00...�-..--... INSPECTIONRECORD over 100M ........................ . 10.00.. ........... Comfort Cooling Unit......to 3 ton/.HP ......................_... 6.00... ............ Forms / Foundation ......... .... ...... ..... .I By:........ . ..... - Date........... to 15 ton/HP.............-..........fr 9.50.............. Plumbing Ground Work . .................... J.... .........._...._........................ to 30 ton/HP.........................`.. 12.00. ............ ugh Electrical ........._.........................�....................._. to 50 ton/HP................. ..........17.00.............. ........................... me - Plumbing and Heating ..........I......................... ........................... Space Heater........ Wall Heater ...................................1 6.00.............. ration & Energy__.......................... .........................)._....._............._- Flues - other than above .............._............................1.. 3.00.............. .:S Test ..._............._._..._....... ..... ... . .................'t......_........_...._.. Vent Fan: Kitchen........ Bath ............................... ._.- .- 3.00............... Temporary Power Gas / Elect. . ......_.........................t....._.................... Commercial Range Hood ......____................... 6.00...-----...... Final - Electrical ........................._.............._.............. . ......................__ �......_................ . .. �� Mise. (See Ord. Current................_........__......... -. ..... Final - Building / Mechanical ..............................-......!_.... ... Permit Fee ...._____........................................................ $ 6.00 J Final - Design Review / Landscaping . .... .............._..... ..................... TOTAL Htg./ Coolg. Permit Fee (plus penalty if app. ❑) $ Final-Public Works ...........................................................