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1921 (2) • add • 4 CITY OF CUPERTINO 1Q APPLICATION FOR RESIDENTIAL BUILDING PEll PERMIT NUMBER AND r� CERTIFICATE OF OCCUPANCY FOR aN1183anJ BUILDING INSPECTION DIVISION STREET ADDRESS OF PROJECT: 01 0- Lpe�j 0pd...1.ri.Ve........_...._..._..._............._..__...... • • • Legal escriphor Traci....<`........... Block...... Lot__.._._........... Description of Work: r.00RL..addIti0A..._.___.__..._.................. PlansReceived By..................................._......._......Date ..._...._._._....... REQ.: Plans.... Survey.... Cates: Struc..... Energy.... Elect..... Mach.... 1st Struct. Improvement on Parcel: Yes.... No Area of Bldg.390 ._.. Plans Checked By......................... .. Date ..,../..._ Separate Structure............ or Addition/Alteration to Exist. Bldg.. Application Approved B ........ ...........Date ... .�. .. App pp y ... .. ..,... .� �" No. of Stories....1.......... Use of Buil Ing reSid.eL1C2 Validated By._......__._..._.._................................_..Date .................__— Valuation of Prole t: $.......1 O 0�0....... ..........- --...._.. Compensation Certificate Verified B ._--. Gle P y ................. Date ................... Owner Mar ....G�atlhard......... Phone: 2 -1F .8 x 7 5 ",3 . .... Contractor: .. � fl .::..._...._.........._.........City Bus. Lia # .none . • • • • • E/ '000 �// Contractor's Address: ................../,. .. Phone:.................:.. Permit Fee (plus penalty if applicable) ....._.— $.../ " — Contractor - Electrical: 5��. ..................._........._........... Plan Check Fee (less deposit of$.......... Rct. #.... $_.................._ City Business License x""""""""""__"""... Phone:...... Plumbing: self ...................................__...................__..._... Energy Plan Check Fee (Dep. of $........ Ret. #........)$_.__.. _...... . City Business License #.......... Phone:......... StrongMotion Fee ..........................................................$........ .. "-" """ Heating and Cooling self.............................___....__........... Plumbing Permit Fee ...................................._..__....$...... City Business License #.........._.. .... Phone:...... Electrical Permit Fee ......................................................$$ ...... - . /'7 �r. ... ... Architect/Desi ggne : self............................. Phone:.._..__..__.... Htg Rech.Residential Construction Permit x ............................ $_._/"�"r O17. Engineer: ... .s2 f..._ ............................_............ Phone:...._.._._.._... Residential Construction Tax ................................._.....$..........._...__... ....... Misc. Fee $.............._..,_.. . .. ._.._.a...n.Self............................................. ❑ Unknown Lender: cerci! that in the performance of the work for which this Misc. Fee ........................................ ...... ........$ '— - v p permit is - q"""'--- � Issuetl I shall not employ any person in any manner so as to become subject • . $for� /# to the workman's compensation Is o California." SIGNATURE OF p • • APPLICANT/OWNER4A�..QS ATE._2.-Z2.-U 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 ......Permit ................ COnd: Use Permit #............ Variance #....... Parking Spaces. ........ I I certify That I am exempt from the "Licensed Required" provisions of the Approved By. Date Contractors License Law. (Stale basis li exemption.) --�-��-��"-�"�--'----------��--'- --"""""""""""""'""' i hacby acknnwiedge That I have read this application and state that the above is xrrect 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 Cf08chment Permit........._............. Grant of Easement............... against liabilities, judgments, costs and expanses which may in any way jorb, Gutter, Sidewalk, Driveway: Replace.......... Repair.......... acture against said City in Consequence of the granting is permit." wBL.......... Conn. Fee $................ Water................ Meter $.... SIGNATURE OF Agreement for Completion of Public Works Improvements ............._... APPLICANT/CONTRACTOR�e!057"..pL�.. E2_-.22-Q� 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 Light Outlets..�J.... APPLICATION FOR PLUMBING PERMIT . Switches..).. .... Fixtures............ Receptacles...../. ... PERMIT INSTALLATION NO. EACH FEE TOTAL NUMBER (less than 1000 watts) ..... ... $ .50 "" "O+00 Gas System with up to 5 outlets ......................... ......$4.00. Range.. .... Cooking Unit........ Oven............ ......... .. 2.00 .-.... .. .. Each additional outlet ...................................... 1.00........O.D Dryer../... Garb. Disp......... Dishwasher ............. 2.00 0 Water System ,(Installation, Alt, or Repair) 4.00..... d7 MOTORS: 1 HP or less ............................._.........,....... . 2.00 �------ -"�� Water Closet./, Water He ter. . Ld. Tray............a- 4.00- � I o c 5 ........ Lavator Shower Pan.. Bathtub Sink........... .. 3 0.......... Greater than 1 HP not more than 5 HIP ........._... . 3. 0 .. ... yam.. .... �.. .0 Temporary Power Pole or Service — 100 amp ........ _5.00 -"__........ Wash. Mach... Dishwasher.... Garb. Disp..... .._....J.... 3.00... ...]4 1 _20( am .......................Y.. .. 8.00. ... p. ....... - 7.00....._...._.. Sewer ................._.............__._.......... .ltd 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 24.60 1751-20000 37.50.............................. ................................ .... 751-1000 26.00 2001-225C 39.50.............................. Permit Fee ............................................ ........................$6.006.00 1001-1250 28.50 2251-2500 42.00.............................. TOTAL PLUMBING PERMIT FEE (plus penalty if app. 7) E ,Od 1251-1500 32.00 2501-2750 49.50.............................. APPLICATION FOR HEATING/COOLING rERMIF PermitFee...............................................$6.00 TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.0) $/g 0 PERMIT INSTALLATION NO. EACH FEE • r Forced Air Unit .. ... t over 100M .........................-.10.00 ...... Forms / Foundation ................... _ .. ....._I By:.. ... _.._ . Date:. "�!�" Comfort Coolin Unit."-"tto l5 ton/HP.........................�" 9.50........_.... Plumbing Ground Work . ........ - 3-�-g to 30 ton/HP...........................12.00- . ..... Rough Electrical ...._............................ �._ . ..9_......_ _L-/�f.'. ........ to 50 ton/HP17.00.. .........0 ame - Plumbing and Heating ..........t.......... 6.00 Space Heater........ Wall Heater ........... . ....�....... �b p ............. . ..... \ Smporary ulation & Energy............................... ......_............__.�.--._..._.....---......._ Flues - other than above ....................._......_..............L. 3.00.............. sTest ._._....___......................... .._................... _..............._.. Vent Fan: Kitchen........ Bath ..._....... ....... .._...... 3.00........... ._ Power Gas / Elect. . ......:. .........._........_...�._----..--------.......... Commercial Range Hood 6.00_. Final - Electrical .............................._.............................�_....._............__- Jpp Misc. (See Ord. Current.............._....._........_....... ........ ..................__... Final - Building/ Mechanical ..............._........._.___ . . . ___._ T Permit Fee ._.....:............_.................._._. ... . .............. $ 6.00 Final - Design Review / Landscaping . ..... ......___._.L..................... , �� rr� Ra v,a QLt•J c- TOTAL SH.t J /,Co_olcg, Permit Fee (Plus penalty 1f app. E]) $/a, Final—Public Works ..... .. ................................................. Poi YRsn1c 9•r Q�