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1601 ...r CITY OF CUPERTINO i4 APPLICATION FOR RESIDENTIAL BUILDING PERMIT PERMIT NUMBER AND FOR APPLICANT TO FILL IN CERTIFICATE OF OCCUPANCY 7 BUILDING INSPECTION DIVISION STREET ADDRESS�OF PR JECT: 06.. u..6._..........2 A..5_..._.Q.Al-fl,?5. ..... ....._._....... • . • Legal Description: Tract..._.._......._.._.. Block.........._ Lot__.................. Description of Work: ........... ...............................- Plans Received By......................_.--------....._.........Date ........................ REQ.: Plans.... Survey.... Calcs: Struc..... Energy.... Elect..... Mech.... 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 ../ '1: .:' No. of Stories.......:........ Use of Building ......_........__._.............-............ Validated By........................ ........_...... Date ................... Valuation of Pro'ect $....-.......... _ .---......_..._.._......_......_...._._........_`._... Compensation Certificate Verified By .............._. Date .... ................. Owner: ............ ..1.1055._...........-..............._...__. Contractor: ...... .....- - ................................City Bus. Lic. # ......... • • " • $ Contractor's Address . . Phone ne. Contractor - Electrical: ... . A.N.<.i.t._ . . ._C..c1 .. )r...e....:......_..- Permit Fee (Plus Penalty If applicable) ........._ ........$ ............-... City Business License #................... Phone:.y.4�'�`��.9 Plan Check Fee (less deposit of$...-..... Rct. #_..... -)$....................... License #. ...... ........ Phone:: Energy Plan Check Fee (Dep. of $........ Rct. #....._.)$........--.._......... Plumbing: ............... _._................... ........ ...... .._...._... Strong Motion Fee ......--..._._............_.....__....._.._....$......_.....-._..... City Business LLice __ Heating and Cooling ..._. #.._............__......... .................. _ Plumbing Permit Fee .. _....................._................_$._................... City Business Licensee #.................... Phone:ne:...................... Electrical Permit Fee ............ _................._..... ........$.../A...... Mach. Htg./Coolg. Permit $............................. $.._....._--...... Architect: Designer: ......_........ ............... ...._.......... Phone:.................... Residential Construction Tax . -........_.... Engineer. ... . ._.._. .._ -. .... .. -. Phone:..... ......... .. ._..._.... Lender: .. ................. ....... -. _....... .. F] Unknown Misc. Fee ......-....--------------------...----__...___........$.-....-............ ^I certify that in the performance of the work for which this permit is Misc. Fee ........ ..................................._...._........._........ ......._.............. issued I shall not employ any parson in any manner so as to become subject • . , , ; $ to the workman's compensation laws of California." SIGNATURE OF /_/1 _ff ZONING - • APPLICANT/ OWNER ......._........ DATE2. ......L.D_U 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 Llcens, No. .i7!LT..$T..b........ Use Zone ............ P.D. Conditions ............. in Classification ......4.LQ....._._. ........ is in full force and effect: or Cond. Use Permit #............ Variance #.... .... Parking Spaces..._....... I certify mat I am exempt from the "Licensed Required" provisions of the _ Approved B ................ Date Contractors License Law. tate basis li exemption. PP Y���------�---��� --�-��--- """"""""""-""" I hereby acknowledge that I have read this application and state that the above Is aorrect and agree to comply with all City Ordinances and State Laws regulating buitmig I (We) agree to save, indemnify and keep harmless the City of Cupertino 1croachment Permit......._.._........... Grant Of Easement................ against liabilities, judgments, costs and expenses which may in any way rb, Gutter, Sidewalk, Driveway: Replace_._._ mi . Repair.......... secure against said City in consequence of the granting of this pert ewer............ Conn. Fee $........--.... Water..... Meter $........_..._ SIGNATURE OF / y Agreement for Completion of Public Works Improvements . .............. APPLiCA NT/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 • • 120 days from validation date, or should authorized construction be suspended or abandoned for a period of 120 days after work is commenced. PERMIT INSTALLATION NO. EACH FEE APPLICATION FOR PLUMBING PERMIT Light Outlets.....9.... Switches. 5...... Fixtures..... ... Receptacles....3 - PERMIT INSTALLATION NO. EACH FEE TOTAL NUMBER (less than 1000 we ..... (d.., g ,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 ... 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-.............. 200amp. ..__.- 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.. ............ 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.............................. 751-1000 26.00 2001-2250 39.50.............................. Permit Fee ..._......._....._...... ( ._........... ......................$8.00 TOTAL PLUMBING PERMIT FEE (plus penaltyallyif app. C]) f 1001-1250 28.50 2251-2500 42.00............... 1251-1500 32.00 2501-2750 49.50.............................. APPLICATION FOR HEATINGICOOLING PERMIT. PermitFee...............................................$6.00 TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.p) $If 7„0 PERMIT INSTALLATION A IFEE Forced Air Unit.............. ...to 100M ..:........_........ .........g 6.00-...-- ----- INSPECTION RECORD over 100M ................ ........ . 10.00.. ........... Comfort Cooling Unit.._.Ao 3 ton/HP .. ... 6.00 I rs / Foundation . .... I By -- .. Date .... to 15 ton/HP 9.50 mbing Ground Work .. .... i... .... -_._. to 30 ton/HP . 12.00..... gh Electricalto 50 . .ti f._. ... _... .. p ....- Wall Heatteron/HP ._ .. . . . 17.00 ..me - Plumbing and Heating ...I__ _ ... -� --- Space Heater - 6.00 lation & Energy........ ..__.._.........._..._......_.............._. Flues - other than above .........._....._........................... 3.00.............. Test . .. ..... .._... ...... _... . . .'hh .. ... .. Vent Fan: Kitchen ....... Bath ... 4. 3.00.. .. . Temporary Power Gas / Elect . ..... ...1 - - .- Commercial Range Hood _ ... J.. 6,00 - Electrical Final ..... ... .... _. -. .. . Misc. (See Ord. Current. . .. Final - Building/ Mechanical -_ - .... __ .. -_ ... ... Permit Fee ___ _ - ........ $ 6.00 Final - Design Review / Landscaping _ .. ...I -.. .-... ... ..__ - ....,r. 9 P 9 � � TOTAL Htg./ Coolg. Permit Fee (plus penalty I app. ❑) E Final-Public Works ........................................................... /v Sheet 2 CITY OF CUPERTINO BUILDING PERttIT Permit PID: / Lo/ Address: aocfrR LAt�ly�/75 • Date: BUILDING PROJECT IDENTIFICATION WORKERS'COMPENSATION DECLARATION Applicant's Mailing Address I hereby affirm that I have a certificate of consent to self-insure, or a certificate of Workers'Compensation Insurance,or a certified g e"d Ss< �4S 6,yms cop% thereof (Sec S00,L3b.C.�. Address of Building Policy No. Company Certified copy is hereby furnished. /e M 0 S Tclepho name _ G ,) Certified copy is filed with the county building inspection Telzphonc ;:o. � �� department or county department. leC. Date Applicant Contractor's Name A _ F P Contiactor's Mailing Address A e•r'- Cr, •7C P• CERTIFICATE OF EXEMPTION FROM WORKERS' NoU114t4).7 s 7 COMPENSATION INSURANCE . - (This section need not be completed if the permit is for one Architect or Engineer - hundred dollars ($100) or less.) Architect's or Engineer's Address I certify that in the performance of the work for which this permit Lic. No. is issued,l shall not employ any person in any manner so as to become subjec to the \Yorkers' Come anon laws,Aq(C liforn�'y LICENSED CONTRACTORS DECLARATION Date /dr Applicant p ¢s NOTICE TO APPLICANT: If, after making this Certificate of I hereby affirm that 1 am licensed under provisions of Chapter 9 Exemption, you should become subject to the Workers' (commencing .with Section 7000) of Di%ision 3 of the Business and Compensation provisions of the Labor Code, you must forthwith Professions Code,and my license is in full force and effect. comply with such provisions or this permit shall be deemed revoked. License Class 4 Lic. NumberX1 iN Date f- 1�/- f1 L' Contractor ec k;•J CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit,is issued (Sec.3097, OWNER-BUILDER DECLARATION Civ.C.).Lender's Name - I hereby affirm that 1 am exempt From the Contractor's License Lender's Address Law for the following reason (Sec.703 L5,Business and Professions 1 certify that 1 have rend this application and stale that the abore Code: Any city or county which requires a permit to construct,alter, information is correct. I agree to comply with all city and county improve,demolish,or repair any structure, rior to its issuance,also P ordinances and state laws relating to building construction,opo and requires tics the applicant for such permit to file a signed statement that hereby authorize representatives pe this county to inter upon the he is licensed pursuant comm o the with act of the Contractor's License above-mentioned property For inspection purposes. Law(Chapter 9(commencing with Section 7000)of Division J of the Business and Professions Code) or that he is exempt therefrom and Signature of Appuceet ar Agent Date the basis for the alleged exemption. Any violation of Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of at more than five hundred dollars (S,iW).): "OWNER-BUILDER VERIFICATION 1,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not "Attention Property Owner. intended or offered for sale (Sec. 7044, ot appness and Professions ..Attention Property building permit has been applied for in Code: The Contractor's n License Law does not apply to an owner of our name and bearing your signature. property who builds or improves thereon,and does such suck y "Please Complete and return this information in the envelope himself or through his own employees, provided that such � pe improvements are not intended or offered for sale.IL however,the provided et your earliest opportunity to avoid unnecessary delay building or improvcmcnt is sold within one year of completion,the in processing and issuing your budding permit.Nobuilding permit owner-builder will have the burden of proving that he did not build wtll be issued until n to provicel ion is received. or improve for the purpose of sale.). 1. I personally plan to provide the major labor and materials for ' n 1,as owner of the property,am exclusively contracting with construction of the proposed properly improvement (yes or no) licensed contractors to construct the project (Sec.7044,Business and Professions Code: The Contractor's License Law does not apply to 2 I (have/have not) signed an application for a an owner of property who builds or improves thereon, and who building permit for the proposed work contracts for such projects with a contractor(s) licensed pursuant to & I have contracted with the following person(firm) to provide ' the Contractor the proposed construction: License Law.). Name 1 am exempt under Sea R.h P.C. for this Address City reason __ Phone Contractors License No. Date Owner 4. 1rov to Ian provide p p portions of the work, but I have hired the following person to Coordinate,supervise,and provide the major work- Name Address City Phone Contractors License No. . . 5. I will provide some of the work but I have contracted(hired) - the following persons to provide the work indicated: Name Address Phone Type of Work - Signed: Property owner Social Security number Date: