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1610 (2) CITY OF CUPERTINO pgg� APPLICATION FOR RESIDENTIAL BUILDING PERMITPERMIT NUMBER ('• AND OHL^:. " ' . . APPLICANT TO FILL IN CERTIFICATE OF OCCUPANCY BUILDING INSPECTION DIVISION ST ES R ECT• • • • • Legal Description: Tract........................ Block............ Lot...................... ` Descriptio of rk: .. .._....... PlansReceived By....................................................Date ...................... REO.: Plans.... Survey.... Cales: Struc..... Energy.... Elect..... MecK'.... 1st Struct. Improvers t on Parcel:Yes.... No..!Area of Bldg............... Plans Checked By................................ Date ......... .) Separate Structure............ or Addition xist. Bldg........... Application Approved By..................A,_.�•...:.....Data ../.L .1. .. No. of Stories.........�.... Use of Building ........ ... .... Validated By..............................................................Date ........................ Valuation of Project:�$....... .....Z�� Compensation Certificate Verified By .................. Date ......................... Owner: .._W 7r........._.................................. Phonel•�. ..:�.... Contractor: ... /'.Ifil i... y9ty us. Lic. * .. .... • ' " • $ Contractor's Address: .2o_y�......G.J. AP,!nso�Phone�'..��:.f. .. Permit Fee (plus penalty f applicable) _ Contractor - Electrical: ....'.T...led.117. ................................ (P P y pP ) ........................$..............--- '' Cit Business License *.. .. .. Plan Check Fee (less deposit of$.......... Rct. #.... $....................... Y j�9G...Phone:.................... Plumbing: ......... .. o. 6j//.9....... ............................... Energy Plan Check Fee (Dep. of 5........ Rct. #.........$....................... - /'n Strong Motion Fee ..........................................................$............... City Business License * ..-f.yp.V Phone:.................... Heating and Cooling .. J' /! ................................. Plumbing Permit Fee ........................................I.......$_........... Cit Business License * .. City ./.�y...... Phone:.................... Electrical Permit Fee ......................................................$..... ..� ..... Architect/Desi Designer: ........... Residential Construction Tax ..:..........................:.........$....................... Engineer: .............................._..................................... Phone:.................... Misc. Fee $....................... Lentler: . ertify..that...,........perf......................................w is C] Unknown ""'-""""""'---""""-"".""....""'-..""""'-.-"""" "I certify s that in the y any ponce of the work for which this permit Is ISC. 80 ........................................................................ ....................... issued I shall not employ any parson In any manner a as t becoma • • , , ; $02 7.Sf) to the workman' com atlon levee of Calllomia" SIGNATURE OF �� • • APPLICANT/OWNS ..... ....._�.`..... ...... TE.. ... Environmental Status: Exempt............ Other....................................... . . '•I certify that as the applicant I a Iconned ane,• the p IWsrtys{�r Design Review Approval: Bldg. ............ Site ............ Sign ............ Contractors Licensa,♦_eyrand rI that my Licens, No. .UJ..�_. Use Zone ............ P.D. Conditions ................. In Classification ... . ......./.. . .. ..__. is in full force and effect: or Cond. Use Permit *............ Variance *............ Parking Spaces............ - I certify that 1 am exempt from the "Licensed Required" provisions of the Approved By. Date Contractors License Law. (Stale basis of exemption.) - "-"""""""""""""-"""""""'""""' """""""""""""' I horeby acknowledge that I have read this application and state that the above Is :orrect and agree to comply with all City Ordinances and Stale Laws regulating ' • • • • Luildmq. - r f " I (We) agree to save, Indemnify and keep harmless the City of Cupertino C. 'QRchment Permit........................ Grant of Easement........................ against liabilities, judgments,costs and expenses which may In any way " b, Gutter, Sidewalk, Driveway: Replace.......... Repair.......... occurs against said City I con once of the gra tin f,t a permit.", er............ Conn. Fee $................ Water................ Meter$................ SIGNATURE OF '/J�aA9J�I�j/.,. -Agreement for Completion of PtibhC Works Improvements .................. APPLICANT/CONTRACTOpCIY`^`�""""".....� ............ T .......` Plans Checked By........ Date........ Approved By........ Dais_................. NOTE: when properly validated this form cons fir. tas a Building Itil 1.This permit expires and becomes null and void should work not.be commenced within • • 120 days from relldatbn date,or should authorized consWetion be suspended or • abandoned for a period of 120 days alter work Is commenced. PERMIT INSTALLATION NO. EACH FEE F. Light Outlets............ Switches............ APPLICATI• • • PLUMBING PERM17 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, All. or Repair) ................. 4.00. ............. MOTORS: 1 HP or less ....................................... .. 2.00 a�ff11 Water Closet.... Water Heater.... Ld. Tray-•-------•---- 4.00- -----••-:-••: Greater than 1 HP not more than 5 HP ........,,,).. . 3.50 ...r31/ 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. f gee Ord. current)...................................................... Vacuum Breakers ............................................ ..............3.50. ..:...:..._ New Residential Occupenciea Flet Rate interceptor........ Water Softener........ ........................._..4.00. .....:....:.'' Plumbing Piping without fixtures .........................::?i:.'..4.00. ........-.,: 0-500 eq. ft. $22.00 1501-1760 $34.50.............................. Misc. (See Ord. Current) ............I——... .,... . . .................... 601-750 24.60 200 -•200C 37.50.............................. TOTALPermit PLUMBINGPERMIT FEE (plus penalty If gip •'••"$8.00,,,;- 761-1000 28.00 2001-226C 39.50.............................. .................................... C• Z]) 1001-1250 28.50 2251-2500 42.00.............................. 1251-1500 32.00 2501-2750 49.50.............................. APPLICATION FOR HEATING/COOLING Permit Fee............. ........................$6.00 .. TOTAL ELECTRICAL PERMIT FEE (Plus penalty If app.p) $pfC PERMIT INSTALLATION NO. EACH "I FEE o // Forced Air Unit................_to 100M ......E e.00... • • - r over 400M...................... . 10. .. 40r00 - -//1W�T'�...`...... 8.00. Forms / Foundation .............................. Comfort Cooling Unit......to 3 ton/HP ................ I BY:........ .:..... . Date:................ to 15 ton/HP........................ 9.50.. . Plumbing Ground Work ...................... 1..... ................ ........................... to 30 ton/HP........................ ..12.00. r' . � •�• • ?ph'Electrical .................... ......... . .......... ................................ Plumbing and Heatinto 50 ton/HP.................. ...... 17.00.. . .... .. ... paceHeater........ Wall Heater ................................. 6.00.. ..........; Rner E 9Y............................... .................................................... Flues - other then above .........:........................:........�.. 3.00:. est ............................................... ................................................. Vent Fan: Kitchen........ Bath .......................................Ir}.. 3.00... ........... ary Range Final- Electrical .................................._ ...............................:................... Misc. (See 10 d. Current tl...........................................A............... ......... Final orBuildgin/rMechanical t• .. . _ f.......................... TOTALPermit F Coolg. Permit Fee (plus penalty i• apPee ..0) 0$ 8.00 ---_F•inal - Design Review / Landscaping l-Public Works ..........................................................I