1008 (2) CITY OF CUPERTINO
APPLICATION FOR RESIDENTIAL BUILDING PERMIT PERMIT NUMBER
AN;
CERTIFICATE 0 OCCUPANCY FOR APPLICANT TO FILL fN
BUILDING INSPECTION DIVISION STRgTV8i PROJQ9T:
..............................
Legal Description: Tract... Block............ Lot......................
?5 ...... ..........
Plans Received By................... .....Date ......................... Description of Work: .... .... ........................
. .... --.. .. .. .
...........
REO.: Plans.... Survey., CaIcs, Struc..... Energy.... Elect..... Mach.... 1st S It u ct. Improvement o IT Parcel: Y a a N.o.. Area. ..o.I...Bldg.-.................
Plans Checked By iL ......................Date 57.1b.:7:. -.0... Separate Structure............ or Addition/Alteration to Exist. Bldg...........
Application Approved Date No. of Stories....-__...... Us of Building ................. .....-.......................
Validated By............. .....................................Date ........................ Valuation kf FJiL9j ts�j.....400
Compensation Certificate Verified By ....-........... Date .....-................ Owner: 41
..-R.Q.(,T!ji....... . ::: PhonM.�;nq.
Contractor: /... ....................... .................'ity Bus. Lic. # ............
$ Contractor's Address: ._........... ........................ Phone:........_..........
Permit Fee (plus penalty if applicable) .... $ 67, 0-6 Contractor - Electrical: ._....._............. .................... .................. .........
Plan Check Fee (less deposit of $.......... Ret. #..........)$... ..... City Business License #.................... Phone:....................
Energy Plan Check Fee (Dep. of $...-... Rct. #........) $.-......-.......0.. Plumbing: ................................ .......____....................__...._...
Strong Motion Fee ...............................R.O..�............-.1-$ .. ,- !;--*.... City Business License #.................... Phone:....................
Plumbing Permit Fee ...Cc...4i........................... $..._....._........... Heating and Cooling ....--...-............ ...........
Electrical Permit Fee . ...........--....... .................... $........-.._.......... City Business License ......... Phone:....................
Mach. Htg./CooIg. Permit $. ..2.q . .............. Architect/Designer: ....... -....................... Phone:....................
$-...... ....... Engineer: . . ..... ..... ..... Phone:_............
Residential Constructi x ................... $...................... Lender:. .. - ... C] Unknown
Misc. Fee ....................1!).................... ... $.._-lu.... ... ....
$ 'I certify in. which this permit is
Misc. Fee .................................. ..... ... !" p�, as to become subject
issued I shall ,a F
$ 60 to the workman' Pon ti rplaws of alilor la."
SIGNATURE OF
APPLICANT/OWNER DATE.�F-��7579.
Environmental Status: Exempt Other....................................... "I certify that as the applicant I am licensed unde the provisions of the
Design Review Approval: Bldg. ---.... Site ...- Sign ........-- Contractors License Law and further that my Licens, No. ............
Use Zone .........- P.D. Conditions ..............................:.............. ........... in Classification - --.....--. ........... is in 1.11 force and effect: or
Cond. Use Permit #........-... Variance #......._... Parking Spaces............ I certify that I am exempt from the 'Licensed Required" provisions of the
Approved By.............................. ................ Date ..... ............. 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
croachment Permit........................ Grant of Easement......... ............ against liabilities, judgments, costs and expenses which may in any way
rb, Gutter, Sidewalk, Driveway: Replace..._....- Repair.......... acture against said City in consequence of the granting of this permit."
war............ Conn. Fee $.........-... Water............. Meter $.........--.... SIGNATURE OF
Isgreement 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 becomes null and void should work not be commenced within
APPILICATION-FOR ELECTRICAL PERMIT 12.1datu ,fo.," vpldation date, or should authorized construction be suspended or
abandoned
don tied of 120 days after work is commenced.
PERMIT INSTALLATION NO. EACH FEE APPLICATION FOR PLUMBING PERMIT
Light Outlets............ Switches............ -07 EACH FEE
Fixtures............ Receptacles............ PERMIT INSTALLATION
TOTAL NUMBER (less than 1000 watts) ..... ....... $ .5o ...... 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 I 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. Difi 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)................................. ........... Vacuum Breakers ........--.........-............ ..............3.50..............1
New Residential Occupancies Flat Rate Interceptor........ Water Softener........ ............ .......... 400
Plumbing Piping without fixtures .....-........................... ..............
Misc. (See Ord. Current)
0-500 sq. ft. $22.00 1501-1750 $34.50..............................
........................... . . ......
501-750 24.60 1751-20000 37.50.............................. .... ....... ..
PermitFee .... .......-..........................................................$6.00 ....
751-1000 26.00 2001-225G 39.50.............................. TOTAL PLUMBING PERMIT FEE (plus penalty if app.C)) $
1001-1250 28.50 2261-2500 42.00..............................
1251-1500 32.00 2501-2750 49.50.............................. APPLICATION FOR HEATING/COOLING PERMIT
Permit Fee...............................................$6.00
TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.0) $ PERMIT INSTALLATION -90-. EACH FEE
Forced Air Unit..................to 100M ... . . ...............$6.00.. ...........
INSPECTION RECORD over 100M ................ ........ . 10.00.. ............
Comfort Cooling Unit....AD 3 ton/HP ........................ - 6.00...............
Forms / Foundation .... .... . ... By:........ . .... Date to 15 ton/HP........................ . 9.50..............
Plumbing Ground Work ... ..... ........ j.... ......-......- ...... ...... to 30 ton/HP................. ..........12.00. ...........
Rough Electr I to 50 ton/HP.... .......................17.00..............
Plug and Heating
......... ................ .... .. .... ...... Space Heater........ Wall Heater .............. ................... 6.00 ............
rgy..:........--........ .......... .......
Off UIL-len * Flues - other than above .......... ................. 3.00.. ............
Test ......-.... ....... .......... Vent Fan: Kitchen........ Bath ........... ............ 3.00.............
porary Power Gas / Elect. ....... ............-....... Commercial Range Hood .....................--....... ....... 6.00
,nal - Electrical ... -........... .......... ........................... Misc. (See Ord. Current............ .......J...........
Final - Building/ Mechanical ................._..._......_....._LPermit Fee .... ...... ........
Final - Design Review / Landscaping ..... ................ - -- - - ............ $ 6.00
...-..................... TOTAL Hlg./ Coolg. Permit Fee.(plus penalty if app. 0) ' $
Final-Public Works ...........................................................