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1691 CIT, Of• Ciii r d CITY OF CUPERTINO JPPLICATION FOR RESIDENTIAL BUILDING PERMIT AND FOR APPLICANT TO FILL IN DEC PERMIT NUMBER �( CERTIFICATE OF OCCUPANCY BUILDING INSPECTION DIVISION STREFT 2ERE g,. PP 1.1 Fy;.9...................................................... • • . • e Legal Description: Tract...... ....... ...,.�glsock............ Lot...................... Description of Work: ......�06 .i.............................................. Plans Received By....................................................Date .................._..... I ........................................................................................................................ REO.: Plans.... Survey.... Celcs: Struc..... Energy.... Elect..... Mach.... tat Struct. Improvement on Parcel:Yes.... No... Area of Bldg............... Plans Checked By................................. .. Date ......... Separate Structure........ or Addition/Alteratio o Ist. Bldg........... ApplicatlonApprovedBy...................�I.. ......-Date L... ...�. .!/. No. of Stories....... Use of Buil i ..... Validated By..............................................................Date .....I................. Valuation of Pr a �$.. . .. ......... . Compensation Certificate Verified By ................. Date ......................... Owner: ....... .. ............. • • • q Contractor: ...? .. . /C ity Bus. Lic.•# ... / H Contracfor'sA dress: . .A.6_.. ..... _ ..... 9.[tox•t�.�u Permit Fee (Plus penalty If applicable) o-ro Contractor - Electrical: .............................................Phon .. PY pP ) ........................$.�................. Plan Check Fee (less deposit of$.......... Rct. #..........)$...................... City Business License a.................... Phone:.................... Energy Plan Check Fee (Dep. of $........ Rct. #........)$....................... Plumbing: ............................................................... :.................... Strong Motion Fee ..........................................................$........I..TV...... r City Business License .. .................. Phone:.................... PlumbingPermit Fee $....................... Heating and Cooling ........................................ne:.................... ................................................ City Business License a.................... Phone:.................... Electrical Permit Fee ......................................................$....................... Architect/Designer: .................. .............. ............ Phone:.................... Mach. Htg./Coolg. Permit $............................. $..................... . . ,.;. Engineer: ..... _..............__................... .. ............. Phone:............... Residential Construction Tax ........................................$....................... Lender: . .. ............................. .............................................. p Unknown Misc. Fee ........................................................................$....-. . ....... Misc. Fee $ ir..� "I certify that In the perlarmance of Ih work for which this permit la -- -- - •- - - ----- -••• issued I shall not employ any p y manner so as to become subject • $Z SSU' to the workman's colawand f California." SIGNATURE OF • • APPLICANT/OWNED ... .............._......._.... DAT �./.. ..... Environmental Status: Exempt............ Other........................................ •I cerlify th a i nt I am licensed uncle the provisions of the Design Review Approval: Bldg. ............ Site ............ Sign ............ Contractors License further that my Licens, No. ............................ .... Use Zone ............ P.D. Conditions ........................................................... In Classification ........................................ is in full force and effect: or . Cord. Use Permit #........... Variance a............ Parking $pacesC85............ - - I cert ily that I am exempt from the "Licensed Ra4ulred" provisions of the Approved ByDate Convectors License Law. (Slate basis exemption.) �����-��---������--�-�-��������-�������"'�������� --""'����""""""' i hereby acknowledgea that I have read Ihl6 application and stale that the above is cenect and agree to comply with all City Ordinances and State Laws regulating • • • Wilding. I (We) agree to save, indemnify and keep harmless the City of Cupertino 0 chment Permit........................ Grant of Easement............_.......... against uabf lilies, lodgments, cost no xponses which may In any way lie Gutter, Sidewalk, Driveway: Replace.......... Repair.......... secure against said Clty In con a of the granting of this permit." r............ Conn. Fee $................ Water................ Meter $................ SIGNATURE OF y,y�/s Agreement for Completion Of Public Works Improvements .................. APPLICANT/CONTRACTO .. ........._......... DATF� J..K Plans Checked By........ Date........ Approved By........ Date.................... NOTE: When properly v ed this form conatltutas a Building arm Thls permit expires and becomes null and void should work not bs nAmmsneed within APPLICATION • • ELECTRICAL PERMIT 120 days from validation date, or should authorized construction be suspended or abandoned for a period of 120 days after work is commenced. PERMIT INSTALLATION NO. EACH FEE APPLICATION • . PLUMBING 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 .........................................r....... . 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.OD .............. Wash. Mach..... Dishwasher....Garb. Disp..... ..... .......... 3.00. ............. —200 amp. 7.00............... Sewer ............................................................................... 8.00............... Time Clock ............................................ ...............I......... 1.50............... Lawn Sprinkler Sys. $5.00 Ea. add Sys. $2.00..................... ............. Misc. (see Ord. current)...................................................... Vacuum Breakers ............................................ ..............3.50-............. New Residential Occupancies Flat Rate Interceptor........ Water Softener........ ........................._..4.00. ............ Plumbing Piping without fixtures ...................................4.00............... D-500 sq, 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 39.50.............................. TOTAL PLUMBING PERMIT FEE (plus penalty if app. 7 i 1001-1250 28.50 2251-2500 42.00.............................. 1251-1500 32.00 2501-2760 49.50.............................. APPLICATION Permit Fee.................. .............................$6.00 TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.p) $ PERMIT INSTALLATION NO. EACH FEE Forced Air Unit..................to 100M ..............................$ 6.00... ............ INSPECTION • ' r over 100M .......................... 10.00.. ........... Comfort Cooling Unit......to 3 ton/HP ........................... 6.00............... Forms / Foundation ............................ . By:........ ....... . Date:............... t015 ton/HP........................ 9.50.............. Plumbing Ground Work . .._....._...._.- )..... ................. .............._....... to 30 ton/HP.........................�..12.00. . ;... ....•••• gh Electrical .................................... ..................... ........................... to 501on/HP...........................17.00.. ........... e - Plumbing and Heating ..........' . ........................... Space Heater........ Wall Heater ....................-......-...... 6.00., ............ W, & Energy......................... .................... 1 I......................... . .. .. Flues - other than above ..................-.-.......................).. 3.00.. ........... Test ........... ........_.._........._ .. .. .'.......................I.......................... Vent Fan: Kitchen........ Bath .........................:............... 3.00............... mporary Power Gas / Elect. ........ .........................�........................... Commercial Range Hood 8.00 Final - Electrical ...................... ........... ..........................�........................... Misc. (See Ord. Current............................................... ........................... Final - Building/ Mechanical .............. ........_.............I........................... Permit Fee ............. $ 6.00 Final - Design Review / Landscaping . ..... ........................................... TOTAL Htg./ Cool Per Fee (plus enalt if a Final- Public Works ........................................................... 9 9• P Y PP• O) $