21511 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES --- USI= BALI
Build' Address:BuildingProject Identification PERMIT N21511
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wn r s ame: ll ne: A A A
Jqq CITY OF CUPERTINO-BUILDING DIVISION , �r
CoalRctoisName: �p N APPLICATION /PERMIT
BUILDING-ELECTRICAL PLUMBING-MECHANICAL CATEGORY CONTROL#
Architect/Engineer: Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(comment- APPLIANCES-RESIDENTIAL € JOB DESCRIPTION
ing with Section 7000)of Division 3 of the Business and Professions Code,and my
license is in fullf e and effect. ��[ PANES
icense Cl Lic.#
Date ContractorUP Td A S
ARCHITECTS DECLARATION 201-100 PS
CO Z I understand my plans shall be used as public records. OVER I AMPS SQ.FT.FLOOR AREA $/SQ.FT.
WW 0 SIGNS ELW CAL 1'
Licensed Professional
OWNER-BUILDER DECLARATION S LC' tjn
LA m
E. I hereby affirm that I am exempt from the Contractors License Law for the
Z O following reason.(Section 7031.5,Business and Professions Code:Any city or
O Z H TEMP. O INST.
county which requires a permit to construct,alter,improve,demolish,or repair
any structure prior to its issuance,also requires the applicant for such permit to PO
file a signed statement that he is licensed pursuant to the provisions of the
3 w Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi-
sion 3 of the Business and Professions Code)or that he is exempt therefrom and
¢ ] the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjects the applicant to a civil penalty of not more than O TSS CHESFI `(/t ocL
CO
e qo five hundred dollars($500). ;FIE RFSI A ELEC SQ.FT.' STORIES TYPE CONSTRUCTION
j ❑1,as owner of the property,or my employees with wages as their sole �_
Z Q comp ensation,will do the work,and the structure is not intended or offered for l
q sale(Sec.7044,Business and Professions Code:The Contractor's License Law
r3 does not apply to an owner of property who builds or improves thereon,and ` OCC.GROUP RES.UNITS
who doessuch work himself orthrough his own employees,provided that such
improvements are not intended or offered for sale.If,however,the building or ' TOTAL:
improvement is sold within one yearof completion,the owner-builderwill have
the burden of proving that he did not build or improve for purpose of sale.). QTY, PLOVANk PERMIT FEE FLOOD ZONE APN
❑I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUA E
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
builds or improves thereon, and who contracts for such p{ojects with a FEE SUMMARY
contractor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
F-1I am exempt under Sec. B&P C for this reasonOUTSIDE
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP I SCHOOL TAX Y_ N
r-11 hereby affirm that I have a certificate of consent to self-insure,ora RECEIPT X
certificate of Workers'Compensation Insurance or a certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lab CJ
Policy# GAS E .SYSTEM-OVER 4( ) RECEIPT#
Comany BUILDING
DIVISION FEES
Certified copy is hereby furnished.city inspection division.
F-1 Certified copy is filed withhthe GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
city
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei t#
(This section need not be completed if the permit is for one hundred dollars
($100)or less.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N_
I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL: ,.yt
Code,you must forthwith comply with such provisions or this permit shall be BUILDING FEE w
W deemed revoked.
d CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that there is a construction lending agency for the perform TOTAL:; ELECTRIC FEE
ante of the work for which this permit is issued(Sec.3097,Civ.C.)
(� 2 Lender's Name PLUMBING FEE
U. H Lender's Address QTY. MECHANICAL PERMIT FEE
U 1 certify that I have read this application and state thatthe above information
MECHANICAL FEE
O W is correct.I agree to comply with all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
d relating to building construction,and hereby authorize representatives of this
N~ cityto enter upon the above-mentioned roe for inspection u ses. ALTER OR ADD TO MECH.Z (We)agree to save, ndemnify an d keep lmless he City of Cupertino Date Receipt#
V against 1!09kties,judgments,coA nd ex enses which may in anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
again aid ity in on en a the ti g of this permit.
.1_xk-qO AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
ignature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
IIealth and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: V
❑Yes M No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? 1301LER-COMP(3HP OR 100,000 BTU) ��"�
❑Yes ❑No 4•/
I have read the hazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Section 25505,25533 and 25534.1
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.! f
responsibility to notify the occupant of the requirements which must be met
prior to issuance of a Certificate of Occupancy. �� al l'ft rry�,
tf/rl1
Owner or authorized agent Date ISSUED BY:
TOTAL: ;
OFFICE COPY
CITY OF CUPERTINO
APPLICATION FOR RESIDENTIAL BUILDING PERMIT PERMIT NUMBER 1 ,/_�
AND • , APPLICANT •
CERTIFICATE OF OCCUPANCY
FILL IN
BUILDING INSPECTION DIVISION SWE3 AppKESS OF PROJECT:
U j
PRESS
e a51F /e I-�-r ✓e. - -
- -
------------ -- ---- .
DEPARTMENT USE
ONLY Legal Description: Tract.- -._..._. ._..-.. Block............ Lot.._....._...........
1�}�d. .t'-lot'+-. .
Plans Received By....................------------------------...-- Description of Work:Date ----------------•---
REQ.: Pans.... Survey---- alcs: Struc. ... Energy.... Elect....- Mectj•... ist StIruct. Improvement on Parcel:Yes--.. No.-. Area of Bldg...............
Plans Checked By._..-----. A.-/w--t,.�- Date f.o.,ZZ.(.-.g O Separate Structure. .- or Addition/Alteration to Exist. Bldg.----------
Application Approved By.-.-_-q,.-p ----------------Date No. of Stories Use,of Building .-._-.
Validated By------------------------------------------------------------Date --------_---_------- Valuation of Project: $- 64
1 f..- -_ .--- -- I - ----- -- -------- ---------------
Compensation Certificate Verified By ------------ Date ------------------------ Owner:Joh n J. $ V-1 a InC._C- •M uiii.... Phone:..............
_ Contractor: City Bus. Lic. # .._..._ _-
• • • $ Contractor's Address: ..... Phone:.-_--._.--.-..._.
C,4 - -
Permit Fee (plus penalty if applicable) --------------------- $_ - ,----- Contractor - Electrical: .
Plan Check Fee (less deposit of$.......... Rct. #-..._....)$................ . City Business License #. _ Phone:-. .................
Energy Plan Check Fee (Dep. of $........ Rct. #........) $ Plumbing: . ..
Strong Motion Fee .-.------------------.-----------------------------------$_._--- � � City Business License #. -. _ -. Phone:...................
Heating and Cooling
Plumbing Permit Fee --- ------ ----- ---- -- - -- -- --$._. . -{ -
City Business License # _... Phone:...................
Electrical Permit Fee -------------------------- -._----- ----$.- ..f1 U.... Architect/Designer:
. ..... . Phone---------------------
Mech. Htg./Coolg. Permit $............................. $-.-/-0f.!/'L----- Engineer:
Residential Construction Tax ....----_.._....._--.._.__----- $------------------..... _ . Phone:..------..._.
Misc. Fee Lender: ❑ Unknown
- -- - - -- _.... --------- ---------------------
Mise. Fee ''I certify that in the performance of the work for which this permit is
- - - - -- --- $ / issued I shall not employ an
p y y person in any manner so as to become subject
TOTAL �Q -- 9 to the workman's compensation laws of California."
SIGNATURE OF
• ZONING REQUIREMENTSAPPLICANVOWNER) DATE0/3/ #*Q
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 full 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.)
f 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 (We) agree to save, indemnify and keep harmless the City of Cupertino
leroaehment Permit--------------.-.-. -. Grant of Easement...- ........ against liabilities, judgments, costs and expenses which may in any way
irb, Gutter, Sidewalk, Driveway: Replace.......... Repair....--- -- accure against said City in consequence of the granting of this permit."
Sewer..---------- Conn. Fee $------ -- - Water................ Meter $.-----------. SIGNATURE OF
Agreement 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
APPLICATION • 120 days from validation date, or should authorized construction be suspended or
abandoned for a period of 120 days after work is commenced.
PERMI� INSTALLATION NO. EACH FEE
Light Outlets_._ ... APPLICATI• •-- Switches_� _.. -
Fixtures.-_ ..... Receptacles...I5. I / PERMIT INSTALLATION NO. EACH FEE
TOTAL NUMBER (less than 1000 watts) __.'3._. $ .50 - --1p-- - 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 _. - y ( p )
- a 2.00 - - Water Closet.-�. Water Heater-... Ld. Tray...... ..../...... 4,OU
Greater than 1 HP not more than 5 HP 3.50 Lavatory.!- Shower Pan.._ Bathtub._ Sink.........,?... . U'
{ . 3.00...
Temporary Power Pole or Service - 100 amp ! ..- { 5.00 -.1L_ . _ - Wash. Mach._ - Dishwasher.... Garb. Disp----- --------------- 3.00............... 9'
-200 amp J ` 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..........•. QJ
New Residential Occupancies Flat Rate Interceptor--.....- Water Softener-- .4.00.
0-500 sq, ft. $22.00 1501-1750 $34.50.............................. Plumbing Piping without fixtures ...................................4,00............... .1
501-750 24.50 1751-•20000 37.50........................... Misc. (See Ord. Current) ....................................................
... L
751-1000 26.00 2001-225C permit Fee 39.50.............................. ------ ----------------------------•---- ••--- $ 6.00 \.
1001-1250 28.50 2251-2500 42,00.............................. TOTAL PLUMBING PERMIT FEE (plus penalty if app. 0) $ G?!
1251-1500 32.00 2501-2750 49.50.............................. • . • •• HEATING/COOLING PERMITq
Permit Fee...............................................$6.00 i
N
TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.j]) $a-200• PERMIT INSTALLATION NO. EACH FEE
INSPECTION • Forced Air Unit ........ ...to 100M --------.... •..... .........$ 6.00..............
over100M ................ ....... . 10.00...............
Comfort Cooling Unit... -.to 3 ton/HP ................. ......... 6,00..............
Forms / Foundation B Date: �.-� to 15 ton/HP....._......... 9,50...............
Plumbing ea bbbrk - 3-2 4VL--- to 30 ton/HP........................... 12.00- -_--_--- Z
Rough Electrical _. _.
to 50 ton/HP .. .. .. ....__-17.00..............
ime - Plumbing and Heating -- Space Heater---- Wall Heater .-....-. .. 6.00--•-,••--
.ulation & Energy-. -- -- .. ......
- t ---- Flues - other than above .............................................l.. 3.00.....
uas Test
__ - I t - - - Vent Fan: Kitchen. Bath .... _..._.. _. -....... 3.00...------------
Final
.........
Temporary Power Gas / Elect. _ ._-- G- ---- ----•- ------ Commercial Range Hood --- ._--- 6,00- --
Final - Electrical - . ... .. . .. .....
- ------ Misc. (See Ord. Current _�aC.T .�<1.C..j-..-...-... ... ..
Final - Building/Mechanical .__.- . ._. -__ . _-. ..-- . __.. Permit Fee
- _-. - ............
$ 6,00Final - Design Review Landscaping re ----... - -----l----
Fi -Public Works .... TOTAL Htg / Coolg Permit Fee penalty 1fapp. E) $/a
.�
fal;%t. tilir 0