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2085 (2) CITY OF CUPERTINO APPLICATION FOR RESIDENTIAL BUILDING PERMIT PERMIT NUMBER SS/ AND FOR TO F17L IN CERTIFICATE OF OCCUPANCY BUILDING INSPECTION DIVISION ST EET DD SS OF PROJECj �y _ t r • • - • Legal D scripD6n Tract.. ... lock .. Lot . Des ription of Work: /�.J`T1C F� �/✓S�igl«.7 4 Plans Received By .................................. .........Date .............._......._ �- /ji rasjo _c9aP a: Y. 0 ...... ...f Bldg ............. REO.: Plans.... Survey.... Cellos: Struc..... Energy.... Eleww� ist trues. Improvement on Parcel: Yes..:. No!.-Area of Bldg-.- Plans Checked By......_... .................._._.._..-Date . Separate Structure............ or Addition/Alteration to Exist. Bldg...... �... Application A roved B ......................... .Date pp pp y .. _. .. a e . No. of Stories............._. Use of Building ValidatedBy.................. ...._.................................. Date ....................... ....._. ....._.......... .. ...-......................... Valuation of Project ._.._._ - "-""""" Compensation Certifies a Verified By ................. Date .._..._................- Owner: flvf/.:..q.i.G.�yr.$.r�.......__......."...- Phone"Viro.c.;l1ir/ Contractor: ...... ....................._..........._...........City Bus. Lie. # .............. • • • - • $ Contractor's Address: ... ..... Phone:..._............. . Permit Fee (plus enaltif applicable) Contractor - Electrical: _.........._.........._.._..... Plan Check Fee (IessQ�WOFof(UPERTM #......._.) $.._................... City Business License x,""""""""."".._.__. Phone:.................... Energy Plan Check Fee (Dep. of $-....... Rct. #........) $...................... Plumbing: ........_....................................._._...... Strong Motion Fee .. - $_.._""""""""""„_- City Business License a..... Phone:.................... 7....,...... Heatin Plumbing Permit Fee ITYh � I y and Cooling ._............_._....._............._..... Electrical Permit Fee ........................_........__.................$. City Business License #..........._._.... Phone:......._........... Mach. Htg./Coolg. Permit $.._...... ........ Architect/Designer: .................. ........ ........Engineer: . . ...............__.._...._ ..... ...............__......_.. Phone:_._.._.._....... Misc. Fee _.__..$....................... lender: . .. . .._.. _._......_ .._. ........._......................._.._.._. ❑ Unknown ... .. "I certify that in the performance of the work for which this permit Is MISC. Fee ...._._..._......._....._......_............._.........._...._.$.........._.._....... Issued I shall employ any perso in any manner so as to become subject • $ to the work ompe on I t Califomla.” • SIGNATURE OF • - • APPLICANT/OWN ..........._...._ DATE al ....................... Environmental Status: Exempt ......_..- Other..._.......... . ...._......... .... "I certify shot as t e applicant I am licensed untle' the provisions of the Design RBVIBW Approval: Bldg. ._...__.. Site ..._._._. Sign ............ Contractors License Law antl further that my Licens. 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 By." "" '"" """"'"""""""""" "" "'"'""" Date Contractors License Law. (Stale basis of exemption.) """"'" - -"""`-"" '-"" """"""' I hereby acknowledge that I have read this application and state that the above is • - • nwl %orrect and agree to comply with all City Ordinances and State Laws regulating building. I (We) agree to save, indemnity and keep harmless the City of Cupertino ,croachment Permit._..................._ Grant of Easement........................ against liabilities, judgments. Casts and expenses which may in any way orb, Gitter, Sidewalk, Driveway: Replace.......... Repair.......... secure against said City in consequence of the granting of this permit." Sewer............ Conn. Fee $.......... ... Water............... Meter $.... .... SIGNATURF OF Agreement for Completion of Public Works Improvements ._-............. APPLICANTICONTRACTOR ...................._. ................................ 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 commenced within APPLICATION • ' ELECTRICAL PERMIT 120 days from validation date, or should authorized construction be suspended of abandoned for a period of 120 days after work is commenced. PERMIT INSTALLATION NO. EACH FEE ismil Light Outlets_.........: Switches_.._- APPLICATION • • ° 1NO PERMIT Fixtures..._...... Receptacles..._. PERMIT INSTALLATION W. 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 -".02- 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............... . ....Ea..........Sys....................... Time Clock .......... ............... .......................__..... . 1.50...._..._.... Lawn Sprinkler Sys. $5.00 Ea. add Sys. $2.00......... ........... ............. Misc. (see Ord. current 1............ ....... ........... Vacuum Breakers ..............3.50............-. New Resgdentl al Occu pandas Flat Rata Interceptor........ Water Softener........ .............................4.D0. ............ Plumbing Piping without fixtures ...................................4.00"" o-500 0 ft. $22.00 1501-1750 $34.50................ .--......... ""•••••••��• Misc. (See Ord. Current) .......... ' 501-750 24.50 1751-20000 37.50.............................. .......................................... 751-1000 26.00 2001-2250 39.50........................ ..... Permit Fee .......--...........-........_.......................................$6.00 1001-1250 28.50 2251-2500 42.00.............................. TOTAL PLUMBING PERMIT FEE (plus penalty if app. ❑) $ 1251-1500 32.00 2501-2750 49.50.............................. APPLICATION •. HEATING/COOLINGPERMIT PermitFee...............................................$6.00 . TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.p) $ PERMIT INSTALLATION NO. E 3'vACH FEE V Forced Air nit......_..._._..to 100M ...................... INSPECTION RECORD U ........$ 6.00............... over 100M ....................... . 10.00.. ........... Forms / Foundation .........._.. ...... .._..I By: . Date:..._.._...... fort Cooling nit.....to 3 ton/HP ......._.._............., 6.00............... Com in Unit Plumbing Ground W r . ....... ... j to 15 ton/HP........_........._._. 9.50,,,""""""",,,, q r� to 30 ton/HP... ... . 12.00. gh Electrical ..[!. i�#ux .. . . ..� f 1 [�.... to 50 ton/HP_. . .. . .17,00 . me - Plumbing and Heating 7l. .... ... . _ ... ...._...__..... Space Heater....... Wall Heater 6.00solation & Energy ....._ . . . . ....... . Flues - other than above ............... 3.00.............. Gas Test ............................._........ .. . ....._....._......_.....�....._.._.........._.. Vent Fan: Kitchen....... Bath ._.................._....... Temporary Power Gas / Elect. .........`.. 3.00............... . ......_......................... .._.._.._............... Commercial Range Hood ( 6.00.. Final - Electrical ._.............. 9 .........................._....._ ........_.__..._..........._......_.._ .._....................... Mise. See Ord. Current......_............._.......__...... Final - Building/Mechanical ...._......_ ( ����"-�-����"-""�-����������-� ................_.......L........._.._......""-' Permit Fee $ 6.00 Final - Design Review / Landscaping . _. . I ....... ._..........._.........._........_..............__... TOTAL Htg./ COOlg. Permit Fee (plus penalty if app. ❑) $ Final-Public Works ........................................................... Sheet 2 CITY OF CUPERTINO BUILDING PErMIT Permit No: � D85 Address: a Date: }� g BUILDING PROJECT IDENTIFICATION WORKERS' COMPENSATION DECLARATION Applicant's %tailing Address I hereby arfirm that I have a certificate of consent to self-insure, or a certificate of\Porkers'Compensation Insurance,or a certified copy thereof (Set SOo,Lab.C.t, Address of Building Policy No. Cumpany ❑ Certified copy is hereby furnished. (/Owner's name s7.r� ❑ Certified copy is filed with the countybuilding inspection Telephone No. / department or county department. Contractor's Name Date Applicant Contractor's Mailing Address CERTIFICATE OF EXEMPTION FROM WORKERS' Lic. No. COMPENSATION INSURANCE Architect or Engineer hundred dollars (Sitio) or less.) (This section need not be completed if the permit is for one Architect's or Engineer's Address I certify that in the performance of the work for which this permit Lic. No. is issued,I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. LICENSED CONTRACTORS DECLARATION Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of 1 hereby affirm that 1 am licensed under provisions of Chapter 9 Exemption, you, should become subject he (commencing with Section 7000) of Division 3 of the Business and Compensation provisions of the Labor o us Workers' Professions Code,and my license is in full force and effect. comply with such provisions or this permit shall be d erred evoked. License Class Lic. Number Date Contractor CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the Performance of the work for which this permit is issued (Sec.3097, O\VNER-BUILDER DECLARATION Cis•.C.). Lender's Name I hereby affirm that 1 am exempt from the Contractor's License Lender's Address law for the following reason (Sec.7031.5, Business and Professions Code: Any city or county which requires a permit to construct,alter. I cerdfv that I have read this application and state that the above improve.demolish, information is correct. f agree to comply with all city and county' P or repair any structure,prior to its issuance,also ordinances and state laws relating to building construction, and requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License hereby authorize representatives of this county to enter upon the Law(Chapter 9(commencing with Section 7000)of Division 3 of the abovementioned property for inspection purposes. Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 Stgnuere or Applicant or Agent Date by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500).): eir , 1,as owner of the property,or my employees with wages as "OWNER-BUILDER VERIFICATION thsole compensation, will do the work,and the structure is not intended or offered for sale (Sec. 7044• Business and Professions "Attention Property Owner: Code: The Contractor's License Law does not apply to an owner of '•An 'owner-builder' building permit hu been applied for in property who builds or improves thereon,and who does such work your muse end bearing your signature. himself or through his own employees, provided that such "Pleau complete and return this information in the envelope improvements are not iniended,or offered for sale.If,however,the provided at your earliest opportunity to avoid unnecessary delay building or improvement is sold within one year of completion,the in processing and issuing your budding permit.No building permit owner-builder will have the burden of proving that he did not build will be issued until this verification is received. or improve for the purpose of sale.). I. 1 personally plan to provide the major labor and materials for ,� 0 1,as owner of the property,am exclusively contracting with construction of the proposed property im icenscd contractors to construct the project (Sec.7044,Business and provement (yes or no) Professions Code: The Contractor's License Law does not apply to 2 I (have/have not) signed an application for a an owner of property who builds or improves thereon, and who building permit for the proposed work contracts for such projects with a contractor(s) licensed pursuant to 3, 1 have contracted with the following person(firm) to provide the Contractor's License Law,), the proposed construction: v �I 1 am exempt under Sec. B.&P.C. for this Name yeas n Address City Date OwryQ Phone Contractors License No. Y q 4. 1 plan to provide portions of the work, but I have hired the ,`{f+Qil1 following person to coordinate•supervise, and provide the major work- Name Address City Phone Contractors License No. 5. 1 will provide some of the work but 1 have contracted (hired) the following persons to provide the work indicated: Name Address Phone Type of Work . Signed: Property owner ' Social Security number "Til, �k_Ir Date _ .__- ___ AL� J .