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1947 (2) rornW CITY OF CUPERTINO 4981 MARAPPLICATION FOR RESIDENTIAL BUILDING PERMIT PERMIT NUMBER . . APPLICANT TO FILL IN �I CERTIFICATE OF OCCUPANCY BUILDING INSPECTION DIVISION STREET AD RES OF P OJ ECT: 11113.c de Sra ...�✓r_ ......._............_.._..._..............._....... r • • • • Legal Description: Tract..............__..._. Block... ........ Lot...................... Description of Work: ...Nlh/�1..."ANTE0VA....lill2w "-"-. " PlansReceived BY....................................................Date ......................... .. t StI..........h._.._ .......__...............of:._..__..........._......a._.......................... REO.: Plena.... Survey.... Calcs: Struc..... En rgy.... Elect..... Mach.... 1st Struct. Improvement on Parcel: Yes.... No... Area of Bldg............... Plans Checked By......................... . j .. Date ..... .......... Separate Structure............ or Addition/Alteration to Exist. Bldg.. Application Approved ""'"""" p PP PP BY-""--�"""" "" ""'-"" """""'....Date .�liZ. _Q./ No. of Stories. Use of Buildi g ..........._..:.. .......... .._.._�............ Validated B .. ....................Date ...................... .._....._ .�--- By........................................ Valuation of Project: $.. ./OGO............._..._.... Compensation Certificate Verified By .................. Date ......_......._....... Ownel: ... .O!/N 8 • • •. . $ x-41) Contractor: . ......................_........_.__...........City Bus. Lic. #'. ........... ,� ....._... - $ Contractor's Address: ........._._............... e:.... ___......__... Phori.... Permit Fee (plus penalty if applicable) d i Contractor - Electrical: ........_._................_.....- ..._._ ...... ................._. ._.._....... .�... .....t....... . Plan Check Fee (less deposit of$.......... Rct. #._.......)$... `cd.L.'o.... City Business License #...._...._........ Phone:.................... Ener Plan Check Fee Da of ) Plumbing: ..................................._.._..:_.....__._.._........................ 9Y (Dep. $..-..... Ret. #...._.. $.................. City Business"License #._.............__. Phone:...._..._......... Strong Motion Fee ................................................_........$_....._..5�... Heating and Cooling ......_._._..........................._............I__...... Plumbingal Permit Fee ..........._................._........_..... ._....._..._.....""" City Business License #......_..._....... Phone:.................... Electrical Permit Fee .....it $.........................................$.._._._........--""- Architect/Designer: ........._....._ . .'......................._.... Phone:.................... Mach. Htg./Coolg. Permit $............................. $....................... Engineer: ..................._..._......._.:..........................__ Phone:.................... j Residential Construction Tax ........................................$....................... Lender: . . ❑ Unknown Misc. Fee ........_._........................................._.............. .$..._. ..... _ __'___.._he performance............._............_._...__...... Misc. Fee ,(J-O is certI s that in the yany prso of the wank for which ethisco permit Ie """"""'"""""'""""'"'"""'"""'"""""""""'-'"'"""'$""-' -'-"-'-'��-- issued I shall not employ an person in any manner so as to become subject Y • • : $ 1 / .5-y m the workman's compensation laws of Cal :' o/r/ SIGNATURE OF • • APPLICANT/OWNE ... DATE.3-....3.-8/ Environmental Status: Exempt ............ Other........................ ...._.... I certify that r e apiol! orn t I au . the provisions of the Design Review Approval: Bldg. . Site Sign ............ Contractors License Law and further that my Users, No. Use Zone _.... P.D. Conditions __ in Classification ....... .__.._....._........._.. is in full force and effect: or Cord. Use Permit #_"_",","", Variance #...... ..... Parking Spaces.._........ I certify that I am exempt from the "Licensed Required" provisions of the Approved B Contractors License Law. (State basis of exemption.) PP Y"""""""-"......._.._._.................._.......___. Date ........................... I horeby 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 builtling, I (We) agree to save, indemnify and keep harmless the City of Cupertino hcroachment Permit....................... Grant of Easement....................... against liabilities, judgments, costs and expenses which may in any way urb, Gutter, Sidewalk, Driveway: Replace......... Repair.......... secure against said City In consequence of the granting of this permit.'' Sewer............ Conn. Fee $................ Water..............._ Meter $_.............. SIGNATURE OF Agreement for Completion of Public Works Improvements .................. APPLICANT/CONTRACTOR ......................................_......_....._... DATE . Plans Checked By........ Date........ Approved By....... Date.................... NOTE: when properly validated this form constitutes a Building Permit. This permit expires and becomesnulland void should work not be commenced within APPLICATION • 120 days from validation date, or should authorized construction be suspended or abandoned for a period of 120 days altar work Is commenced. PERMIT INSTALLATION NO, EACH FEE Light Outlets............ Switches............ APPLICATION FOR PLUMBING PERMIT Fixtures............ Receptacles......__.. PERMIT INSTALLATION I 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 HE __........_ . 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 1...................................................... Vacuum Breakers ......___....................:...._..... ..............3.50............_. New Residential Occupancies Flat Rate Interceptor........ Water Softener........ .............................4.00. ............ Plumbing Piping without fixtures ...................................4.00............... 0-500 sq. ft. $22.00 1501-1750 $34.50.............................. Mise. (See Ord. Current) ......................... 501-750 24.60 1751-20000 37.50.............................. ••••••••••••.••••••""" 761-1000 26.00 2001-225C 39.50.............................. Permit Fee ......-.................................................................$ 6.00 1001-1250 28.60 2251-2500 42.00.............................. TOTAL PLUMBING PERMIT FEE (plus penalty if app. ❑) $ 1251-1500 32.00 2501-2760 49,50.............................. APPLICATION FOR HEATING/COOLING PERMIr Permit Fee...............................................$6.00 TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.p) $ PERMIT INSTALLATION 0.1 EACH FEE Forced Air Unit..................to 100M .....................-...... '$6.00............... • ' ... over 100M ................ . 10.00.. ........... Comfort Cooling Unit......to 3 ton/HP -........................ 8.00............... Forme / Foundation _._.............._......... BY:.. ..... . ..... . Date:................ to 15 ton/HP......._................ 9.50.............. Plumbing Ground Work .___.._..._.._ . .._.___......_...._....._.......... to 30 ton/HP......................... ..12.00. - ........... Rough Electrical ....................._............. ._... .. ... . _ 9 . . . ... ...._ ..................._._. to 50 ton/HP..._............ ....... 17.00.............. time - Plumbing and Heating ...._.. I. .........._............... Space Heater........ Wall Heater ......_........................_ 6.00 ulation 8 Energy _. �. _. .{.. ..... Flues - other than above . 3.00 as Teat .-... . _... ._. - � Vent Fan: Kitchen Bath .. 3.00 Temporary Power Gas / Elect ... ---- . Commercial Range Hood 8.00 hh .. ....... Final - Electrical .. .... _. .4 Misc. (See Ord. Current ... . _ ..... Final - Building/ Mechamcal . .... Permit Fee .............._............ .. .......................... $ 8.00 Final - Design Review / Landscaping .. .. .. ..................... TOTAL Htg./ Coolg. Permit Fee (plus penalty If app. ❑) $ Final-Public Works ........................................................... APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY • BUILDING PROJECT I DENTIFICATION PERMIT NUMBER BUILDING APPLICATION & PERMIT 3977 ADORf' ELECTRICAL-PLUMBING-MECHANICAL . J 7 7 ] / 77uBUILDING OWNERS PLAN CHECK VALIDATION NAME QTY. ELECTRIC PERMIT FEE PHONE N NERACTORs OUTLETS-SWITCHES-RECEP 5.00/1.00 OSS kel.CieLIC.NO LIGHTING FIXTURES ' 5.00/1.00 CONTRACTOR'S [APPLIANCES 4.00 ' AOOREss ' 3Q PHONE I 0� PANELS 5.00 DATE OF APPLICATION ORRCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO. ENGINEER' ' LIC.NO. SIGNS TRANS. 3.00 ARCH.08 ENG. _ SPECIAL CIRCUIT 5.00 PERMIT VALIDATION AESS ZIP TEMP.METER OR POLE INS. 15.00 ADDRESS T'S ADDRESS MOTORS SEE FEE SCH. V10 SERVICE CHANGE PAID 10.00 p 02 LICENSED CONTRACTORS DECLARATION a u I hereby affirm that 1 am,licensed under provisions of Chapter 9 ISSUANCE DATE v,Q u (commencing with Section 7000)of Division 3 Of the Business and BLDG. ELECT. PLG. MECH. r w i Professions Code, my license is in full for rid f •- ❑ ❑ z o m - Licens ass Llc.Numbe [� CIry �~< �Up6ff�11� 9 z D Date Contiac s7 N H N H J ¢ s BIW,p�ERMIT ¢ w OWNER-BUILDER DECLARATION - KITA TION w ;e y 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO'ORD VALUATION S/FT. u o¢ Law for the following reason.(See.7031.5,Bhsinessand Professions PERMIT ISSUANCE - 6.00 Iw0f Code:Any city orcounty which requiresa permit to construct.alter, �ildf2In ¢ a, Q O improve,demolish,or repair any Structure,prior l0 its Issuance,also ELEC.CONTR. LIC.NO, ELEC. 1''11 till❑_moi a /Y A wD, requires the applicant for SUCK permit t0 file a Signed statement that , TOTAL PERMIT TO //t/J-7,101[•, Ire is licensed pursuant to the provisions of the ).fDi,tofs License z i Law(Chapter Professions Codeng with Section is exempt the on therefrom the and L?Y�mIW C1'RT ¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE ¢ H O the basis for the alleged exemption.Any violation of Section 7031.5 malty STORIES TYPE CONSTR. n ; $ by any applicant fora permit subjectsthe(S504licam toacivil Penalty ALTER-DRAIN -WATER (EA.) 4.00 of not mom than five hundred dollars(55007): ' ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS their sole compensation,will do the work,and the structure is not intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 50.FT.FLOOR AREA TOTAL ACREAGE 4p himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-1 4.00 mems are not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 IEA) 100 BUILDING USE builder will have the burden of proving that he did not build or im- . . . _RES IND CON PB Omer prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑ licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 5.00 ASSESSORS PARCEL NO. and Professions Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts for such projects with a contractors)licensed pursuant to the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO, PARCEL NO. ❑ 'I um exempt under Sec. ,B.&P.C.far this WATER HEATER W/VENT 4.00 reason Date Owner WATER SYSTEM 4.00 PCC.DATE ACC.FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. - 4.00 I hereby affirm that I have a certificate ofconsent to sell-insure, ZONING ENG.SITE NO. or a certificate of Workers'Compensation Insurance,or u certified _ copy thereof l5ec.3800,Lab.Cpang 1.9,A* 0 /r__ .. Policy No. Company Y� /�4 O ❑ Cerli5 cc yy"hereby fD yI. FIRE] INK ENERGY T 24 N Z Z �Certifi py is filed w' the city inspection division. MISC.- REFER TO ORD. O Applicant - x - Y❑ N❑ Y ❑ N❑ PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U,C. LU > CERTIFICATE PE 9ATIO TINS FROM WORKIiRS' - W _ COMPENSATION INSURANCE PLG.CONTR. _ LIC.NO. PLG. CL O ITbls section need not be completed if the permit is for nna TOTAL Y❑ N❑ I Y ❑ N❑ :D Z- hundred dollars IS 100)or less.) U O 1 certify that in the performance of the work I'or which this per- QTV. MECHANICAL PERMIT FEE FEE SUMMARY LL F mitis issued,I shall not employ any person in any manner so as to U become subject to the Workers Compensation Laws of California. O w BUILDING / S� y Date APPLICANT: I - ALTER OR ADD TO MECH. 4.00 } to NOTICE TO APPLICANT: If,after making this Certificate sa fix-. _ f- Z eruption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN'CHECK 7 9 2 provisions io the LaborMise Code, you must forthwith comply with - FEE / CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT TO 10,000GF.M.) 3.00 ' CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10ODOC.F.M.) 5.00 SEISMIC FEE _ I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00 the performance of the work for which this permit is issued ISee. MICROFILM 3097,CiVC.). / ' HEATING UNIT(TO 100,000 B.T.U.) 4.00 / Lender's Name Lender's Address H EATI N G U N IT I OV ER 100,000 B.T.U.)7.50 ELECTRIC 6 I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 information n correct 1 agree to comply with all city and roomy PLUMBING ordinances formatio and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00 hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL. above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,jqdgments, costs and expenses which CONST.TAX ma way accrue n fftsl said City in consequence of the PERMIT ISSUANCE 3.00 ` thispenn it. MECH.CONT. LIC.NO. MECH. Q n -- f U TOTAL- Z-11 TOTAL �7y� n [6R of ApplWmHJCOntractor Date ' OFFICE COPY