1081 (2) CITY OF CUPERTINO lb
APPLICATION FOR RESIDENTIAL BUILDING PERMIT PERMIT NUMBER
�\ AND
' J\1 CERTIFICATE OF OCCUPANCY FOR APPLICANT TO FILL IN
BUILDING INSPECTION DIVISION STY ES eJEPROG_T5� /D
/_..../ ° .. e. 1��t77 r/c.........__..............._...._..
• • Legal Description: Tract.. 1111... Block..... .. Lot......................
........._ Description of Work: 1111 A:CL........WL. f..._..............._........
Plans Received By........._................._.............._......Date . .............. - .
.................__._._........e .._..._-... .._....... ..........101 .._7._.._............_.._._..
REO.: Plans.... Survey.... Calcs: Strut..... Energy.... Elect..... Mach.... 1st Strutt. Im rovement on Parcel: Yes.... No... Area of Bld
P g..g...........
Plans Checked By................... Date 1111... 1111 Separate Structure........._. or Addition/Alteration to Exist. Bldg...........
Application Approved BY-_...A.A L,..._...._1_111_..Date ...'.� ,f�.... No. of Stories .... Use of Building .................. ..........:.._................
Validated 6
y................._........_....................._..........Date ....................... ValuationProject• $._.. ...
Compensation Certificate Verified By ................. Date ......................... Owner: Phone-.f
Contractor: _e 1111 / 'l� City Bus. Lic.
• • • - • $ Contractor's Address:/�/7.b..Se•..FIJI" /'V 1 aQyJ '/
..5.'...5,... Phon
Permit Fee (plus penalty 1 applicable) $_.. _........... Contractor - Electrical: .. .........._....__._..._..._._......._....
Plan Check Fee (less deposit of$......_.. Rct. #.......... $......._......._...:. City Busy1nes�ss,,License #_................. Phon9�� /...
Energy Plan Check Fee (Dep. of $........ Rct. #.... $........_...._1111... Plumbing: ..C'. J.G............................_.....
Strong Motion Fee _..._......................._.....1111.. _T. $......._.. ._ City Business License #.................... Phone:................
.-.
Heating and Cooling 1_111._..
Plumbing Permit Fee .............
�...Tl...�._-_1111.._..._.._.$_....f.Y...•.D0 9 9
,___$_____________________ City Business License #.................... Phone:..........._.....-.
Electrical Permit Fee .........._................_..._u T�1}�l� Architect/Designer: .. ._............_........_._._.....-_.... Phone:.._................
Mach. Htg./Coolg. Permit $..............^............... $._........._......... Engineer: . . .. .
Residential Construction Tax .....l.�I IV,..r. .._.....__....$...... n -......_.............._.._._......_.............__... Phone:..._._...........
Lender: ... 1111..-.
Mist. Fee ....................... ..............1111.1111. . $._..._........__._ .._.. ..__ ......................._........_.............. Unknown
Misc. Fee ......................................1111 . ..�.... '...$....................... "I certify he Performance of the work for which this permit is
/h� n t
"J'-� --• issue I'shall not employ any person in any manner so as to become subject
• $ I0. 00 to the worJtha
' ponsation laws�fcalifomnr ."SIGNATURE OFAPPLICANT/OWN / �ATIE..Environmental Status: Exempt............ Other........._..:._._...._.............. "I rerhly e applicant amte uprpyi,�}}'ryryy1A,pAjj e
Design Review Approval: Bldg. 11__. ... Site ............ Sign .......... ContractoqLav� ndxoluriher the y Licens.Use Zona P.D. Conditions in Classili (_.... ..@. ......_.... is in full force and effect: or
d"
Cond. Use Permit #... Variance #......_.... Parking Spaces............ . . I certify that tam exempt from the 'Licensed Requireprovisions of the
Approved By. _ _ pate Contractors License Law. (State basis of exemption.)
..........
" ""'"`.."`"'"""""""'"'..... "'"""'"...."'"'"" I hereby 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
/ building.
I (We) agree to save, indemnify and keep harmless the City of Cupertino'
r08Chm Bn1 Permit........................ Grant Of EeSement.......... ............ against liabilities, judgments, casts and expenses which may in any way
� ' /b, Gutter, Sidewalk, Driveway: Replace.......... Repair.......... acture against said City i onsequence of the erring of this permit."
_. ..ewer._......... Conn, Fee $......_..._ .. Water._...._....... Meter $.........._1111 SIGNATURE OF
Agreement for Completion Of Public Works Improvements ..._..... ...... APPLICANT/CONTRACTOR .�i/� '.FZ....._ 111,1.. �j/�G�
Plans Checked By...... . Date........ Approved By........ Date.... ............... NOTE: When properly v aled this form an s a Building Permit. This
permit expires antl beco s null and void III prk not be commenced within
• • ' 120 days from valitlalio date, or should eutho' d Ponslrvctlon be suspended or
PERMIT INSTALLATION NO. EACH FEE abandoned for a period of 120 days alter work is commenced.
APPLICATI
Light Outlets............ Switches.......... . • • . PLUMBING
Fixtures............ Receptacles... ... PERMIT INSTALLATION NO. EACH FEE
TOTAL NUMBER (less than 1000 watts) 1111._1111. $ ,50 --...-...... Gas System with up to 5 outlets ......._..............1111._...$4,00 .............
Range........ Cooking Unit........ Oven............ ......._....... 2.00 . ...... Each additional'outlet ................._............_.1__111.. 1.00...............
Dryer...----- Garb. Disp.... Dishwasher ...._....... ...... 2.00 _ ...... Water System (Installation, Alt. or Repair) ............ 4.00
MOTORS: 1 HP or less .......1_.............11...... ....... ......._ 2.00 .....---. Water Closet.... Water Heater..( Ld. Tray.....-----....) .. 4.00. _.`--OD
Greater than 1 HP not more than 5 HP .............. . 3.50 1.....111... . 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 ... 700 .......... Sewer ........ .. _....._
-. 1111.. .._ _.. 8.00...... ..
Time lock 1111 _ 1 50 1111._... Lawn Sprinkler Sys. $5.00 Ea. add Sys. $2.00.....................
_........ ._.__1111_1111.
1111.........
Isc, see Ord. current).. .. .... ....... .............................
..... .. Vacuum Breakers ............ ... ..............3.50..
n_.......1111._......... 1111.._1111
New esldentlal Occupancies Flat Rata Interceptor.._.... Water Softener........ _....4.00.
1111.. ............
Plumbing Piping without fixtures ...................................4.00..
0-500 sq. ft. $22.00 1501-1750 $34.50............... .... ...
"""""
501-750 24.60 1751-20000 37.50.........:.................... Misc. (See Ord. Current) ....................................................
75f-1000 26.00 2001-2256 39.50.............................. Permit Fee ............. .............................. ... .........$600
1001-1250 28.50 2251-2500 42.00.......................... TOTAL PLUMBING PERMIT FEE (plus.... penalty if app. [1) $ .�.
1251-1500 32.00 2501-2750 49.50.............................. APPLICATION • • COOLINGPERMIT
PermitFee...............................................$6.00
TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.p) $ PERMIT INSTALLATION NO. EACH FEE
RECORD
Forced Air Unit.._..............to 100M .....1_111.._1111..1111.._.$ 6.00...............
INSPECTION • r over 100M ......................... 10.00.. ...........
Forms / Foundation ............... ..
... .. ..... .I By ...to_.... . ..... . Date:................ Comfort Cooling Unit... 3 ton/HP ........ .
..._.... .......... 6.00... ........_.
Plumbing Ground Work ... f.. to 15 ton/HP................. ........ 9.50 ...........
........._..... _......_......... 111_1.
agh Electrical ............. 11_11... ..._.....I.
to 30 ton/HP ............
..... ._.1_.......12.00- ..._.......
.. ..... .............. ................_1111.._.
to - Plumbing and Heating .I——....I................. to 50 ton/HP...........................17.00..............
__............._...._.._.._._ Space Heater........ Wall Heater ...........................1111... 6.00
soon 8 Ener ..................... � p ..............
9Y ......... .._.....__......_._. .......................... Flues - other than above ....._._................................_.. 3.00..............
Nest ....__......Ga_......_lec ....... .. . ......._....._.....'__............_._..... Vent Fan: Kitchen........ Bath ........_....._............-. ._ .. 3.00...............
Final orary Power Gas / Elect. ........ 1..._...._... 1111 Commercial Range Hood ..............._............_.....I__ 6.00
.. 1111 _..__........_......_ 9
Final - Electrical .............. 1111 .. ...............
.._......_........_ .................._....L.....................""- Misc. (See Ord. Current ........_......_._.........._._................
Final -Design
Building/ Mechanical ................. I Permit Fee $ 6.00
............................._1111 _..
Final - Design Review / Landscaping . ............. ..............._.......__.........................._..._._....._.
" "-- """""........------ TOTAL Htg./ Coolg. Permit Fee (plus penalty if app. ❑) $
Final-Public Works ...........................................................