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1251 CITY OF CUPERTINO PPLICATION FOR RESIDENTIAL BUILDING PERMIT PERMIT NUMBER AND FOR APPLICANT TO FILL IN CERTIFICATE OF OCCUPANCY BUILDING INSPECTION DIVISION STRE T ADDREgS OF ppOJECT: .D...S../Q...yt•.NRt.S t......D ................ ................. • • • - . Legal Description: Tract........................ Block............ Lot............Y..... Description of World: fr"A4E...... /yf1N�E..'< ........... PlansReceived By....................................................Date .................. ..... ...../9lI ........,/a.0.r.. ............................................................. REO.: Plane.... Survey.... Calcs: Strue..... Energy.... Elect..... Mech.... 1st Struct. Improvement on Parcel:Yes.... No... Area of Bldg............... Plane Checked By.................. Date ........ Separate Structure............ or Addition/Alt ration to Exist. Bldg........... 'Application Approved By.....J'r......L.....................Date ..�.L! . .. .... No. of Stories....../....... Use of Building All... ............................... ValidatedBy.............................................................r Date ....................... Valuation of Project: $........ ..................................................................... Compensation Certificate Verified By ...._........... Date ......................... Owner; .M0 .5'7.rl.3..... ....................... Phone:.................... • • • • e § Contractor:I? F{....LI4FA.%./y(.���_*k.Cit Bus. Lic. # .............. . Contractor's Address:WAX . ......Lz........1 r..�Phone:.................... Permit Fee (plus penalty if applicable) ...:....................$....................... Contractor - Electrical: .............................................................................. Plan Check Fee (less deposit of$.......... Rot. #..........)$...................... City Business License #.................... Phone:.................... Ener Plan Check Fee De of $........ Rot., Plumbing: ..................................._......................................... 9Y (Dep. )$....................... City Business Licens 0.................... Phone:.................... Strong Motion Fee .............................. ..........$....................... Heating and Cooling/j. N A/.G.ATl-Vill.... PlumbingPermit Fee ...............(.r,,).."............., $.......................�1'• City Business Licen e,#�6.,Ze.C�.. Phone:z.�lC67"2.2 Electrical Permit Fee .....................................�.�J.......$.............p.U.... Architect/Designer: ......_........... .............................. Phone:.................... Mech. Htg./Coolg. Permit $........ .t;moi.....:..... $.....��5........... Engineer: Phone:.................... tt• g' ................................ ..........._...................... Residential Construction Tax ..........r.:7................ a�ttee Unknown Misc. Fee �....P:r....................... Lender: .... ............................. ............................................. O ......................................................ti.............$....................... .� I ... is certify that in the yperformance person of the work for which this permit is Misc. Fee ................................................. ..............................................�- �............$....................... Issued I shall not employ on arson in an manner so as to become subject t"""""' P Y Y p Y I s § to the workman's compensation laws of California." SIGNATURE OF • • APPLICAN7/OWNER ............._........................................................ DATE........................ Environmental Status: Exempt............ Other........................................ 'I certify that as the applicant I am licensed unde the pr v signs of e Design Review Approval: Bldg. ............ Site ............ Sign ............ Contractors LicenseJ�ew 0�d l�urlher that my Llcens. No. 445 y��J... Use Zone ........... P.D. Conditions in classilicalion ....L: L-0 - Is in full force and effect: or .....#................a Parking Cond. Use Permit #............ Variance #............ Parking Spaces............ I ceniry that I am exempt from the "Licenced Required" provisions of the Approved By. Date Contractor, License Law. (State basis of exemption.) - --^----- --'---"-- -'-- - - -`-""--""""""" I hereby acknowledge that I have read this application and elate that the above Is correct and agree to comply with all City Ordinances and State Laws regulating • • buildmq. • I (We) agree to save, Indemnify and keep harmless the City of Cupertino f9reernent achment Permit.::..................... Grant of Easement........................ against liabilities, judgments, coals and expenses which may In any way Gutter, Sidewalk, Driveway: Replace.......... Repair.......... secure against said City In consequence of the granting of this permit." ........... Conn. Fee $................ Water................ Meter $............... SIGNATURE OF �'`'�`/f''�,for Completion Of Public Works Improvements .................. APPLICANT/CONTRACTOR ' .�....... DATE 77!:•?..?E... Plane Checked By........ Date........ Approved By........ Date.................... NOTE: when properly validated this form eenatlgbs a Building Permit. This permit expires and becomes null and void should work not be commenced within • s 120 days from validation date, or should authorized consimetlon be suspended 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 I FEE TOTAL NUMBER (less than 1000 watts) .....I....... $ ,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 ..............................................................L. .. . 1.50............... Lawn Sprinkler Sys. $5.00 Ea. add Sys. $2.00..................... ............. Misc. (see Ord. current).............................I........................... Vacuum Breakers ............................................ ..............3.50. ............ New Residential Occupancies Flat Rate Interceptor........ Water Softener........ .............................4.00. ............ Plumbing Piping without fixtures ...................................4.00............... 0-500 eq. ft. $22.00 1501-1750 $34.50.............................. Misc. (See Ord. Current) ••••••••••••••••••••••••........................•••• 501-750 24.50 1751-•20000 37.50.............................. Permit Fee ..........................................................................$6.00 751-1000 26.00 2001-225C 39.50.............................. ITOTAL PLUMBING PERMIT FEE (plus penalty If app. ^M) $ 1001-1250 28.50 2251-2500 42.00.............................. 1251-1600 32.00 2501-2750 49.50.............................. APPLICATION FOR HEATING/COOLING Permit Fee...............................................$6.00 TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.[]) $ PERMIT INSTALLATION NO. EACH FEE Forced Air Unit..................to loom ....................... -$6.00... ...^^.. INSPECTION • • r Over 100M ........................ . 10.00 • ' Comfort Cooling Unit......to 3 ton/HP ........................�. 8.00... ..-.-. g BY:........ . ..... . Date:............... to 15 ton/HP......................... 9.50.............. Plumbing g Ground Work ... .............. ...... ................................._........ � to 30 ton/HP ......................... ..12.00.... ............ Forms Foundation.on ............ .. ........._. .........._......._._. to 50 ton/HP................ .17.00.. . ....... ........... e - Plumbingand Heating6.00„ )........................... Space Heater........ Well Heater ................................... ........... ......................... 1 IlUporarylation & Energy........................ .. ..........................�........................... Flues - other than above ..................................... ..... 3.00.............. Test .............................._... ...... .�.... . ........ _._.�.. ..... .. ... .... Vent Fan: Kitchen_...... Bath ......_._..........._....... .......... 3.00............... Power Gas / Elect. ........'.........................�........................... Commercial Range Hood 6.00,,, Final - Electrical ....................................)........ ....... ...I 9 .......................................... .. ............ .. . .. .I........................... Misc. (See Ord. Current........................................................................... Final - Building/Mechanical ..............1........................I........................... Permit Fee ........................................................................ $ e.00 Final - Design Review/ Landscaping . .... ........................................... TOTAL Htg./ Coolg. Permit Fee (plus penalty if app. p) $ Final-Public Works ...........................................................