1692 (2) • CITY, pF CUPERi1N0 •
CITY OF CUPERTINO
APPLICATION FOR RESIDENTIAL BUILDING PERMIT �E PERMIT NUMBER 9ci
AND FOAPPLICANT TO FILL IN
R• CERTIFICATE OCCUPANCY
BUILDING INSPECTION DIVISION ST,�a T ADYR SS pF PROJECT: g
r...Yar .VJ. 0. ..�1.[41.....................................................................
• . - . Legal Description: Tract.....................(.�Block... .. . Lot......................
Description of Work: ...SL?IL(C....tlCf_(-` .....P4$O.LS.........................
PlansReceived By--....................._....................._.Date ......................... .............-_._..__......-...---_.............................-...-.........__............................
REQ.: Plans.... Survey.... Calcs: Struc..... Energy.... Elect..... Mach.... tat Struct. Improvement on Parcel:Yes.... No... Area of Bldg...............
Plans Checked By.......-................0. ....p ..:......_..Date ...f..�.�f6-_.� Separate Structure............ or Addition/Alteration to Exist. Bldg...........
Application Approved BY.........................................Date ......................... No. of Stories................ ...
Usy,�ofl6.3.uiJJding .................. . ...........................
Validated By.......---.................................................Date ........................ Valuation of Project: $. .. . .
Compensation Certificate Verified By ................. Date ....... ........ Owned V rY.l.Oe�t"'A'
.. r'..�. ............ity Phone:....... .
9 Oontractory.. �'Lfh 1'U-CC.. OlkV.............Pity Bus. ne: .;.39.1
• • • • • $ � 13 �o J Contractor's Address?._ �...�Q!C_ISIunA......_ Phone:: .k*.-1,704
S�, Contractor - Electrical: .................................... ....._..........................._.....
Permit Fee (Plus penalty if applicable) ........................$........./.............. City Business License #.................... Phone:....................
Plan Check Fee (less deposit of$.......... Rct. #..........)$- ;1,6.y .....
Plumbing: ......._......._....... ...............--...._........ .....__...........
Energy Plan Check Fee (Dep. of $........ Rct. #........) $................. .. City Business License *........... ..... Phone:e:....................
Strong Motion Fee ..__..............-......-.........._.........._...$.._....._. " Heating and Cooling ........
0 0-D.. ..........................................................
Plumbing Permit Fee ..._........................_........._.....$..../_._' City Business License *..._............... Phone:....................
Electrical Permit Fee ....................-...............................$....- --o. ... Architect/Designer: ......_..-..............................-..... Phone:....................
Mach. Htg./Coolg. Permit $............................. $...----........... Engineer: .. Phone:....................
.-.....................................................--...
Residential Construction Tax ......._........_.......__..........$...................... Lende � . .. ...._..... 0 Unknown
Misc. Fee $. .i_.the ..._......................_..._._.... which
........................................................................ ...................... "I certil [hal in the '
.. .. y performance of the work for which this a subject la
Mlle. F¢¢ ........................................................................$..........d.......... issued I shall not employ any person in any manner so as to become sublecl
• . , $ 9 a i.Z0 to the workman's compensation laws of California."
SIGNATURE OFA , _
• • blUNAII)i OF NER '.. .. ..........._..... ..`..'_�._.`..•.................__.... DATE..-' .� .0
Environmental Status: Exempt ............ Other..._.......... ................. 'I certify that as the applicant I am licensed unde the pr ; a sof,the
..... ... q4yy pp 11
Design Review Approval: Bldg. _.......... Site _.._...... Sign ........_.. Contractors License La�y and further that my Licens. No. ...3 ..L.. v..._..
Use Zone P.D. Conditions in Classification _......_ ............. ....____. is in full force and effect: or
......rmi .....*................arks............ccs............
Card. Use Permit *............ Variance *...... ..... Parking Spaces............ I certify that I am exempt from the "Licensed Required" provisions of the
Approved B . Date Contractors License Law. (State basis of exemption.)
PP Y - --- --- - ----' '------' """"'--"""""""" 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
WORKSPUBLIC • building.
I (Wel agree to save, indemnify and keep harmless the City of Cupertino
encroachment Permit........................ Grant Of Easement........_.............. against liabilities, judgments, costs and expenses which may in any way
�rb, Gutter, Sidewalk, Driveway: Replace.......... Repair.......... secure against said City in consequence of the granting of this permit."
war............ Conn. Fee $................ Water................ Meter $................ SIGNATURE OF -f ❑�
Agreement for Completion of Public Works Improvements ................I. APPL ICA NTS CONTRACTOR/C• .f.r.�t.d.�-. ........................._ DATE hZ:.I_l..r.W
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 FOR ELECTRICAL PERMIT 120 days from validation date, or should authorized construction be suspended or
abandoned for a period of 120 days alter work is commenced.
PERMIT INSTALLATION NO. EACH FEE APPLICATION FOR
Light Outlets............ Switches............
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, Alt. or Repair) ................. 4.00...............
MOTORS: 1 HP or less ..... ..... ........................ ....... . 2.00 S:v . Water Closet.... Water Heater.... Ld. Tray..................... 4.00. ..............
Greater than 1 HP not more than 5 HP ....... ... 3.50 ..3.v....... 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......... 7.00-1............ Sewer .....-.................-...............................................-- 8.00...............
Time Clock ................. ................_ ..... ...... ........... Lawn Sprinkler Sys. $5.00 Ea. add Sys. $2.00..................... ..._....._-
Misc (sae Ortl current) . . ............. . ................................. 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 $34.50.............................. Misc. (See Ord. Current) ......................... �...:.,—
...........................
501-750 24.50 1751-20000 37.50.............................. Permit Fee ...... .........-.........................................$ 6.00
751-1000 26.00 2001-2250 39.50.............................. TOTAL PLUMBING PERMIT FEE (plus penalty if app. Q) t 0, 0-a
1001-1250 26.50 2251-2500 42.00..............................
1251-1500 32.00 2501-2750 49.50.............................. APPLICATION FOR HEATING/COOLING PERMIT
Permit Fee...............................................$6.0.0
TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.p) $9 PERMIT INSTALLATION NO. EACH FEE
Forced Air Unit.........._......to 100M -............................$6.01............
INSPECTIONRECORD over 100M ...................:- . 10.00.. ...........
Comfort Cooling Unit.....to 3 ton/HP ........................... 6.00... ...........
Forms / Foundation __._........ .. By:... .... .. . Date:.............. to 15 ton/HP..._............ ......., 9.50..............
Plumbing Ground Work . ........._.._..... _.............. .........__._...._..... to 30 ton/HP...........................12.00. ............
Rough Electrical ....._....._....._,._......_.. I...... ._............ ......-.................. to 50 ton/HP......................_....17.00.. ...........
. .........
....._ ...._...... 6.00
Tame - Plumbing and Heating __...... .................._........ Space Heater........ Wall Heater ........_........................ .. ....
l _._..._.
ulation & Energy........---..........__.. ...... ..._...--....._ ............... Flues - other than above .............. _---............................ 3.00. ...........
Test ................._.............. ... ...._...__._.........L._....................... Vent Fan: Kitchen........ Bath _......................................`.. 3.00...............
mporary Power Gas / Elect. . ........ .........._............ ........................ . Commercial Range Hood 1, 6.00...............
g ................................... .........
Final - Electrical __.......... .......... ......................... .-....................... Misc. (See Ord. Current................_..._............._...
Final - Building / Mechanical .............. ........................I........................... Permit Fee ...............-......... ....................$ 6.00...
Final - Design Review y Landscaping '�
9 P 9 - -- -- ----------.....-- TOTAL Htg./ Coolg. Permit Fee (plus penalty i app. Q) $
Final- Public Works ...........................................................