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1769 CITY OF CUPERTINO LLqq + APPLICATION FOR RESIDENTIAL BUILDING PERMIW61 �' L NVr PERMIT NUMBER 76 jAND FORAPPLICANT , FILL IN. I` • CERTIFICATE OF OCCUPANCY , ON1183d(l, BUILDING INSPECTION DIVISION S O7 ,R0SS ( fJE\177z4K 134i111:111 I"A40 IMI&I • Legal Description: Tract..... ........_lock...... ... Lot............:......... Description of Work: _ i G,rru _ �........... Plans Received BY....................................................Date :........................ t _,........_........_......_._................ .............._................_................................ REO.: Plans.... Survey.... Cafes: Struc..... Energy.... Elect..... Meeh....\V!A 1st Struct. Improvement on Parcel:Yes.._ No... Area of Bldg...._......... Plans Checked By.................................... . Date ...r....-,y. '\�T.1 Separate Structure............ or Addition/Alteration to Exist. Bldg........... Application ApprovedBy..............Y6.,..L.,i..„.,,,, Date .. .. �. No. of Stories................ Use o tiding Validated By......._........._.............................._....._..Date ._......._............ Valuation of Project:-�$....a .(7O.w............................................... Compensation Certificate Verified B ..... Date ......................... Phone:..........:......... P Y ............ Owner: /✓filSrr•.... ll.y b -......_........... ... .... I Contractor: .yGaGi('. ...jCity Bus. Lic. w ....... • ' • • $��� - � ! Contractor's Add ss; .... !,�,-..�Rscn.w_I...... Phone3.?7.1.ei Permit Fee (Plus penalty if applicable) ........................$J9 __ .' 1 Contractor - Electrical: _.____................._..................................._.......... Plan Check Fee (less deposit of$.......... Rct. ......................#..........)$. City Business License #.................... Phone:.................... Energy Plan Check Fee (Dep. of $........ Rct. #........)$......__............. Plumbing: ..................................._......... ......—.............................. Strang Motion Fee ..........................................................$........r.-:f7p..... City Business License #...........-........ Phone:.................... Heatingand Cooling .................—.............__................._.......... Plumbing Permit Fee ................................................$....................... City Business License #.................... Phone:.................... Electrical Permit Fee Permit $................._..................-....$._......._.._....... Architect/Designer: ......................._........................ Phone:._............_... Mach. Htg./Coolg. Permit $............................. $._.................... Engineer: .:.......... ............................_._..................... Phone:................... Residential Construction Tax ........................................$..-.................... Lender: . .. ❑ Unknown Misc. Fee ......................_..._...........................................$_.... .._... "I certify that in the mince Mise. Fee _..._...._................. „$,,..�.._ ^” "' y y any person in the work for which this permit Is """""""""""""""""""' "'^'-"' issuetl I shall not employ an p y y person f any manner so as to become subject • $� D, ,{Z) to the workman's compensation laws of li/Ornla." SIG URE OF • • A PILIOANT/OWNE Environmental Status: Exempt ............ Other..............._ ................. "I certify that as the applicant I a C. uncle' the pr v e o the ... ... ,p��s gn Design Review Approval: Bldg. ............ Site ..._..__. Sign _......... Contractors License�L�77w oanOd Wither that my Licona, No.,}.CfjtO .(... Use Zone P.D. Conditions - 'Yin Classification .....f.-:..JJ................ is in full force and effect: ar ............ .......................................................... Cond. Use Permit #............ Variance #......__.. Parking Spaces............ i certify that I em exempt from the "Licensed Required" provisions of the Approved B Contractors License Law. (Stale basis of exemption.) PP Y ..__.........._.................................. Date ._....._................. I hereby acknowledge that I have read this application and state that the above Is • co rrncl 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 roachment Permit........................ Grant of Easement........................ p y in any way against liabilities, judgments, costs and expanses which me o, Gutter, Sidewalk, Driveway: Replace.......... Repair.......... secure against said City In conse uan0e of ho granting of this permit." dWer............ Conn. Fee $................ Water................ Meter $................ SIGNATURE OF Agreement for Completion of Public Works Improvements ........._....... ` APLICANT/CONTRACTOR-j /-h'). R .. .... DATE Plans Checked By....... Date........ Approved By.... ... Date............._._ ` NOTE: When property validated this form ca Itute a Building Permit. This permit expires and becomes null and void should work not,be commenced within • • 120 days from validation date. or should authorizedconstructionbe suspended or abandoned for a period of 120 days alter work Is commenced. PERMIT INSTALLATION NO. EACH FEE' APPLICATION FOR 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 .............. 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..................... ............. Misc. (see Ord. current)...................................................... (}� Vacuum Breakers ............................................ ..............3.50.........-.._. New Residential Occupancies Flet Rata ill Interceptor........ Water Softener........ ..... ............4.00. ............ Ar� Plumbing Piping without fixtures ...................................4.00 ,,,-_„-,.... 0-500 sq. ft. $22.00 1501-1750 $34.50..............................1111 Misc. (See Ord. Current) .......... 501-750 24.50 1751-20000 37.50.............................. ................................6.00 .... Permit Fee .....................FE . ............nalt........................8 8.00 751-1000 28.00 2001-2250 39.50.............................. t TOTAL PLUMBING PERMIT FEE (plus penalty if app. '❑) _ 1001-1250 28.60 2251-2500 42.00..............................� 1251-1500 32.00 2501-2750 49.50.............................. • • . HEATING/COOLING PERM117 PermitFee...............................................$6.00 TOTAL ELECTRICAL PERMIT FEE (Plus penalty If app.0) $ PERMIT INSTALLATION 11 0.1 EACH I FEE Forced Air Unit..................to 100M ..............................$ 6.00............... 1 M. r over ZOOM........................ . 10.00.............. Comfort Cooling Unit.._..to 3 ton/HP ....................._.... 8.00............... Forms / Foundation .r............................ By:........ ....... . Date:................ to 15 ton/HP........�................ 9.50.....FE..... Plumbing Ground Work . ......._......... ........ _... ................ _ ............. to 30 ton/HP......................... ..12.00.............. Rough Electrical ...............—............... ....................._............._.._.. to 50 ton/HP......................... .,17.00.. ........... '�me - Plumbing and Heating ................_.....:........... ........................ 6.00 Space Heater........ Well Heater ................................... .............. daTest tion & Energy._................— ....... ....................._.. ........................... Flues - other than above ...—............................... ....._.' 3.00.............. s ` ......................................_.. _........_........ .....I..._....._........_..... Vent Fan: Kitchen........ Bath ........:.........._.................... 3.00............... Temporary Power Gas / Elect. . ..............._................__...._............__- Commercial Range Hood 8.00... .......................................... .. .......... Final - Electrical .................__...... ........ ......_ ...........-,........._.............. Mise. (See Ord. Current...... ......._.._.........................................._ ... Final Building/ Mechanical ....................................... ................. Permit Fee .................................................... ............_... $ 6.00 Final - Design Review y Landscaping . ...... _......._......_.. .. . . TOTAL Htg./ Coolg, Permit Fee (plus penalty it app. ❑) $ Final—Public Works........... .......... (.. .. _A1f ."YJ� ....... — •eu'wp '1 ��— - Sheet 2 CITY OF CUPERTINO BUILDING PERI4IT a Permit No: yy v\Address: Date: ��r('� BUILDING PROJECT IDENTIFICATION I7 ORKERS'COMPENSATION DECLARATION Applicant's Mailing Address 'v7y /W'r. 1 hereby affirm that I have a certificate of consent to self-insure, or a certificate of\Porkers'Compensation Insurance,or a certified o copy thereof (Sec SX,Cu pangLb,C., 1 j address of building ��7�� Aa L ��' �/ Policy No. Company I ,\ B Certified copy is hereby furnished. Owner's name mss, k9 r PS Certified copy is filed with the counh• building inspection �. Telephone No. � � department or county *Partmen 1 Dale F/1—d/ Applicant ' Contractor's Name ti( �s• �t �4�. Contractor's Mailing Address CERTIFICATE OF EXEMPTION FROM WORKERS' sf - COMPENSATION INSURANCE Lie.No. Architect or Engineer hundred dollars ($100) or less.) (This section need not be completed if the permit is for one - Architect's or Engineer's Address I certify that in the performance of the work for which this permit Lie. No. is issued,l shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. LICENSED CONTRACTORS DECLARATION Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of I hereby affirm that I am licensed under provisions of Chapter 9 Exemption, you should become subject to the Workers' (commencing with Section 7000) of Division 3 of the Business and Compensation provisions of the Labor Code, you must forthwith Profession Code,and my license is in full forte and effect. �/ comply With such proyisiens or this permit shall be deemed revoked. License Clpss 9 Lie. Number �q / Date -/—�- Contractor / CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the Performance of the work for which this permit,is issued (Sec.3097, OIVN EA-BUILDER DECLARATION Civ.C.).Lender's Name I hereby affirm that 1 am exempt from the Contractor's License Lender's Address Law for the following reason (Sec.7031.5, Business and Professions I certify that I have read this application and stale that the above Code: Any City or county which requires a permit to construct,alter, information is correct. I agree to comply with all city and county (r improve,demolish,or repair any structure,prior to its issuance,also - ordinances and state laws relating requires the applicant for such permit to file a signed statement that to building construction, and he is licensed pursuant to the provisions of the Contractors License herebv authorize representatives of this county to enter upon the Law(Chapter 9(commencing with Section 7000)o(Di,isionJ of the above-mentioned property for inspection purposes. Business and Professions Code) or that he is exempt therefrom and Signature of AppUeaat or A the basis for the alleged exemption. Any violation of Section 70315 g`vt base by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500).): 1,as owner of the property,or my employees with wages as "OWNER-BUILDER VERIFICATION their sole compensation,will do the work,and the structure is not intended or offered for sale (Sec. 7674, Business and Professions "Attention Property Owrer: Code: The Contractor's License Law does not apply to an owner of '.'An 'owner-builder' building permit has been applied for In property who builds or improves thereon,and who does such work your name and bearing your signature. himself or through his own employees, provided that such "Please complete and return this information in the envelope improvements are not ini ended or offered for sale. If,however,the provided at your earliest opportunity to avoid unnecessary delay building or improvement is sold within one year ofcompletion,the in processing and issuing your budding permit.No building permit owner.builder will have the burden of proving that he did not build will 6e Issued until this verification is received. or improve for the purpose of sale.). 1. 1 personally plan to provide the major labor and materials for ' F1 I,as owner of the property,am exclusively contracting with construction of the proposed property improvement (yes or no) licensed contractors to construct the project (Sec.7044,Business and 2 L (have/have not Professions Code: The Contractor's License Law does not apply to - ) signed an application for a an owner of property who builds or improves thereon, and who building permit for the proposed work. contracts for such projects with a contractor(s) licensed pursuant to 3. I have contracted with the following person(firm) to provide the Contractor's License Law.), the proposed construction: 0 1 am exempt under Sec. , B.&P.C. for this Name reason __ Address City. Dale Owner 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. S. I will provide,some of the work but 1 have contracted(hired) the following persons to provide the work indicated: Name Address Phone Type of Work 0 Signed: Property owner Social Security number Date: