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1872 CITOF YPEIf CUPERTINO PPLICq.'LL l FOMESIDENTIAL BUILDING PERMIT PERMIT NUMBER �� tt CC U AND FOR APPLICANT TO FILL IN CERTIFICATE OF OCCUPANCY ' NO INSPECTION DIVISION SMEET ADDRES OF ROJECT: .................. -^........ • • • • Legal Description: Trac. ............. Block............ Lot...................... Description of Work slt ..........:..................................................................... PiensReceived By....................................................Date ......................... ........................................................................................................................ REO.: Plane.... Survey.... Cafes: Struc..... Energy.... Elect..... Mach.... tat Struct. Improvement on Parcel:Yes.... No... Area of Bldg............... Plans Checked By................................ Date ...''...yy-................ Separate Structure............ or Addition/Alteration to Exist. Bldg........... Application Approved By.................A.....L.........Date ..:/3�.�./....... No. of Stories................ Use of Building .................. ............................... Validated By............................-...............................Date ......................... Valu ti of Project: ...... .. ........................................... pp Compensation Certificate Verified By ................. Date ........................ wner�v.�C .k,� . ..ApIn T...................... Phon y Contractor: .......... ......... .............................City Bus. Lie. Or .............. • • •• • $ Contractors Address: ................-............................ Phone:.................... Permit Fee (plus anal If applicable) _ Contractor - Electrical: ..................... ..........--.......................................... penalty pP ) ........................$.................. City Business License a.................... Phone:.................... Plan Check Fee (less deposit of$.......... Rct. #..........)$...:................... Plumbing;C Energy Plan Check Fee (Dep. of $........ Ret. #........)$....................... ...................................................................................... Strong Motion Fee ..........................................................$..................... Heating and Cooling ..........................................City Business License #.................... Phone:.................... ........................ Plumbing Permit Fee ................................................$....//b.. ..' City Business License e.................... Phone:.................... Electrical Permit Fee ......................................................$...... x.A.1.... Architect/Designer: ...................................._............ Phone:.................... Mach. Htg./Coolg. Permit $............................. $....................... Residential Construction Tax ........................................$....................... Engineer: ..........................._...........--.......--............ Phone:...............wn Misc. Fee $....................... Lender: . ertify....................perf......................................w c ❑ Unknown ""'"""""""""""""""""""""""""""""""""'" "I certify that In the pedormence of the work for which this Permit is Mist. Fee ........................................................................ ........ ............. issued 1 shall not employ any person In any manner so as to become subject to the workman's compensation laws of California." - SIGNATURE OF • • APPLICANT/OWNER ......................................................................... DATE........................ 'Environmental Status: Exempt............. Other........................................ "I certify that as the applicant I am licensed undethe provisions of the Design Review Approval: Bldg. .-........ Site ............ Sign ............ Contractors License Law and further that my Llcens. No. ............................ Use Zone :........- P.D. Conditions .......................................-................. in Classification .....................,..._ -......... is In full force and effect: or Cond. Use Permit #............ Variance #............ Parking Spaces............ I cedify that I am exempt from the "Licensed Required" provisions of the ----- - - -- Approved By. '" ^"""""' """""""""""""'Date Contractors License Law. (State basis of exemption.) I hereby acknowledge that I have read this application and state that the above Is •• s correct and agree 10 comply with all City Ordinances and Stele La" regulating • building. 1 (We) agree to save. Indemnify and keep harmless the City of Cupertino OBChment Permit........................ Grant of Easement.................... against liabilities, judgments, coats and expenses which may In any way .,• , Gutter, Sidewalk, Driveway: Replace.......... Repair........., acture against said City In cormequanpe or true granting of this permit." er............ Conn. Fee $................ Water................ Meter $................ SIGNATURE OF \' 9� 1-3• ,(}/ Agreement for Completion Of Public Works Improvements .................. APPLICANT/CONTRACTOR .. .....r . . . ...... ............ ... ....... 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 void should work not be commancod within • • • 120 days from validation debt, or should authorized construction be susparM•d or abandoned for a period of 120 days after 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. Dep......... 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 .......I.... 3.50 .............. Lavatory.... Shower Pan.... Bathtub.... Sink.................. 3.00. ............. Temporary Power Pole or Service — 100 amp .1...... ..5.00 .............. Wash. Mach..... Dishwasher....Garb, DIED..... ............... 3.00.. ............. —200 amp. 7.00....... .... Sewer ............................................................................... 8.00.......... .. Time Clock ................................................................ ...- . 1.50-.li.S Lawn Sprinkler Sys. $5.00 Ea. add Sys. $2.00..................... ...�t�.�.. Misc. see Ord. current ...................................................... Vacuum Breakers ..3.50.. New Residential Occupancies let Rate Interceptor........ Water Softener........ .................:.........:.4.00. ............ .••.•...••., Plumbing Piping without fixtures ...................................4.00,,,•........... 0-500 0 ft. $22.00 1501-1750 $34.50.................. Misc. (See Ord. Current) .................................................... 501-750 24.60 1751-20000 37.50.............................. Permit Fee ..........................................................................$6.00 751-1000 26.00 2001-2250 39.5o.............................. TOTAL PLUMBING PERMIT FEE (plus penalty if app. 1001-1250 28.60 2251-2500 42.00.............................. 1251-1600 32.00 2501-2750 49.50.............................. • , Permit Fee...............................................$8.00 TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.0) $7 PERMIT INSTALLATION NO. EACH FEE Forced Air Unit..................to 100M ..............................$ 6.00............... INSPECTION RECORD -1 over 100M ........................ . 10.00.. ........... Comfort Cooling Unit......to 3 ton/HP ........................... 6.00... ........... Forma / Foundation ............_................ By:._.._. . ..._ . Date:................ to 15 ton/HP................._ 9.50.............. Plumbing Ground Work .......-........__ I..... ....... ........................................... to 30 ton/HP........................ ..12.00.............. .................................._J... .............__..........._.................. to 50 ton/HP_..........................17.00............... e - Plumbing and Heating ..........I ......I.................... 6.00 tht,Electrical oIt & Energy.........:................ Space Heater........ Well Heater ................................... .............. .....:................................................... Flues - other than above ............................................ 3.00..Test .....................:..................... . .............. .............................. Vent Fan: Kitchen........ Bath ....................................... 3.00.............. orary Power Gae / Elect. ........ . ............................................... 6.00............... Commercial Range Hood .........................................: .. Final - Electrical .................................... ......................... ........................... Misc. (See Ord. Current..................................................,........................ Final - Building/ Mechanical ..............J*.�� ....... Permit Fee ................... $ 6.00 Final - Design Review / Landscaping .... ........................................... TOTAL Htg./ Coolg. Permit Fee (plus penalty if app. p) $ Final-Public Works ...........................................................