1631 (2) CITY OF CUPERTINO
fPLICATION FOR RESIDENTIAL BUILDING PERMIT PERMIT NUMBER
AND •• APPLICANT TO FILL INCERTIFICATE OF OCCUPANCY
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BUILDING INSPECTION DIVISION t/ STSOF PROJ CT:'
r • Legal Description: Tract.............%.......... Block............ Lot......................
DescriIon o Wor� . ............
PlaneReceived By....................................................Date ......................... ..........L�o.o.. ............d-[.fr .-................................................................
REO.: Plans.... Survey.... Cafes: Struc..... nergy.... Elect..... Mach.... 1st Struct. Improvement on Parcel: Yes.... No.... Area of Bldg...............
Plans Checked By...................... ... ..............Date ........ . Separate Structure............ or Addition/Alteration to Exist. Bldg...........
Application Approved By........... ...:... .. .:...........Date ,/. . ..S... .� No. of Stories................ U,5$oI BB it�'ng .................. ...............................
Validated By....:.............................-.........................Date!. ................. ii Valuation of Project: $..."!/�S.CJU.......................................................
Compensation Certificate Verified By ................. Date ........................ Owner: ....... .... Phone:....................
.... ..............
$ Contractor: .A4rF1.1. .. .. h:5/... _� ... fly Bus. Lia r'..............
Contractor's Address:c j'2..33.......:....... .............. Phone:pU.C.'.O.Y.Y
Permit Fee (plus penalty If applicable) �,.... Contractor - Electrical: .............................................
P Y PP 1 ........................$................. City Business License #.................... Phone:....................
Plan Check Fee (less deposit of$.......... Rot. #..........)$..a.2...A-d....
Plumbing: ............................................................ne:....................
Energy Plan Check Fee (Dap. of $........ Rot. #.....-)$.....................
Strong Motion Fee ..........................................................$.........A.,5j6... City Business License #.................... Phone:....................
Heating and Cooling ........................................... ....................
Plumbing Permit Fee ................................................$.../3....,'�.Q... City Business License #.................... Phone::....................
Electrical Permit Fee ......................................................$......6...51.. Architect/Designer: ........................._....................... Phone:....................
Mach. Htg./Coolg. Permit $............I................ $....................... Engineer: .................. Phone:....................
..................................................
Residential Construction ax ........................................
.......................
Lender:
e..nder: . ............ ....................................... ..
E] Unknown
Misc. Fee ........................................................................$....................... "I certifythatIn the performance of the work for which this permit is Fee ' •' '
5I• � issued I shall not employ any person in any manner so as to become subject
to the workman's compensation laws of California:'
SIGNATURE OF
• • APPLICANT/OWNER ......................................................................... DATE........................
Environmental Status: Exempt............ Other........................................ ,.... .... "I certify that as the applicant I am licensed uncle' 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 full force and effect: or
Cone. Use Permit r....,..,..., Variance r............ Parking Spacesccs............ I certify that I am exempt from the "Licensed Required" provisions of the
""""""""""""""""""""""""""""" """""""""""""'
Approved By. Date Contractors License Lam (Slate basis of exemption.)
I hereby acknowledge that I have read this application and state that the above Is
:orrect and agree to comply with all City Ordinances and State Laws regulating
• •• • building.
n I (We) agree to save. Indemnify and keep harmless the City of Cupertino
;t roa0hment Permit........................ Grant of Easement.-.................... against liabilities, judgments, costs and expenses which may In any way
Gutter, Sidewalk, Driveway: Replace.......... Repair.......... acture against said City I ue of the granting of this permit."
or............ Conn. Fee $................ Water................ Meter $............... SIGNATURE OF 'F
Agreement for Completion of Public Works Improvements .................. APPLICANTfCON R cTOR . ........ .. .............._ +......... DATE/.L..:,.....6
Plans Checked By........ Date........ Approved By........ Date.................... NOTE! when property validated this form constitutes a Building Permit. This
permit expires and becomes null and void should work not be commented within
APPLICATION •R ELECTRICAL PERMIT 120 days from validation date, or should authorised construction be suspended or
abandoned for a period of 120 days after work is commenced,
PERMIT INSTALLATION NO. EACH FEE APPLICATION
Light Outlets....... Switches............. - PERMIT INSTALLATION � NO. EACH FEE
Fixtures............ Receptacles
TOTAL NUMBER (less than 1000 watts) ..... ....... $ •50 .....*.`Zi 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 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..
.............
Time Clock ...................................................................... 1.50............... Lawn Sprinkler Sys. $5.00 Ea. add Sys. $2.00....J............._.. .............
Misc. see Ord. current 1...................................................... Vacuum Breakers ............................................ ...! ...3.50.... ...��
New Residential Occupancies Flat Rate Interceptor........ Water Softener........ ...................... .....4.00. ............
Plumbing Piping without fixtures ...........................x.....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
.............ally..
761-1000 26.00 2001-2250 39.50.............................. TOTAL PLUMBING PERMIT FEE (plus penalty i1 app.Q)
1001-1250 28.60 2251-2500 42.00..............................
1251-1500 32.00 2501-2750 49.50.............................. APPLICATION F• • HEATING/COOLING PERMIT
Permit Fee...............................................$6.00
TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.p) $6 SQ PERMIT INSTALLATION NO. EACH FEE
Forced Air Unit.................AD 100M ..............................$6.00...............
' • ' r over 100M ....................... . 10.00..............
...................... . .. .
Forme / Foundation ............... .............. By:........ ........ . Date:................ Comfort Cooling Unit......to 3 ton/HP ..... 6OD.
to 15 ton/HP......................... 9.50.. .....................
Plumbing Ground Work ......... (_ .. ..........._.............................. to 30 ton/HP........................ ..12.00.
gh Electrical - � .......•
....._................_..__.....;.............__....._. ................_......... t0 50 ton/HP......................... .17.00..
in - Plumbingand Heating •
..... ................. ........................ 8.00
9 .. ... .... ... Space Heater........ Wall Heater ...................................
lT Test
8 Ener 1
gY...............................�.................................................... Flues - Other than above ............................................1.. 3.00.. ...........
Test ............. .... ..................... . ..... ............................................ Vent Fan: Kitchen........ Bath ......................................... 3.00...............
emporary Power Gas / Elect. . ........1........................:�........................... Commercial Range Hood 8.00,,,............
Final - Electrical .....................
............... ......................... .......................... Misc. (See Ord. Current...........................................................................
Final - Building/Mechanical .............. .......................I........................... Permit Fee .°...................................................................... $ 6.00
Final - Design Review f Landscaping . _.. ............................................ TOTAL Htg./ Coolg. Permit Fee (plus penalty if app. ❑) If
Final-Public Works ...........................................................