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1679 • CITY. OF, CUPERTINO • • '� CITY OF. CUPERTINO DEC 151980 APPLICATION FOR RESIDENTIAL BUILDING PERMIT p ID PERMIT NUMBER 6 G� AND • . APPLICANT TO FILL IN CERTIFICATE OF OCCUPANCY BUILDING INSPECTION DIVISION STREE�AfeF/SS F P90JECT: ..................... • • • • • Legal Description: Tract ...:......./ Bloc ..,lam..... Lot:... ................. Description of Work: .. /.ML.>.E'.......9P.L�'pa/ f/A,................. Plans Received By..................__..............................Date ......................... .._......................-----...................._................_..........__......----_....._............... REO.: Plans.... Survey.... Cates: Struc..... Energy.... Elect..... Mach.... 1st Struct. Improvement on Parcel: Yes..., No.... Area of Bldg............... Plans Checked By.....................,L Date .................._---- Separate Structure............ or Addition/Alteration to Exist. Bldg........... Application Approved By....._✓T.... ...................Date ../2 7- S'..E-0 No. of Stories................ Use oJ,�yitQ'L Validated BY .--___ -...... - ....Date -- ....... Valuation of Project $. ... %p[.5..��. . ... ..........--. Compensation Certificate Verified By ..._ ..... Date Owner /vl p RR..�! K / le,l . Phone: $ �i�s"— Contractor.G t/Sf6/5 .Pm/il Cit Bus. LIc * ' ' • • • / Contractor's Address. /fid A'F'?114�oneSd 8 tl Permit Fee (Plus penalty it applicable) .�- - $ . ... Contractor - Electrical: ._ .........__........ _ ..__...___............ *Li ................ Phone:.... i City Business cense __ Plan Check Fee (less deposit of $......_.. Rct. #...__...)$._.................. --------- Energy Plan Check Fee (Dep. of $........ Rct. #........)$..........._.._..... Plumbing: ....._........ __......City Business License *..._. ...... . Phone:.... .............. ... ............. ....... ....... .............. ..........__. 5v __- _ Strong Motion Fee ......._....... _........_ ......._._....._.......$.................._._- Heating and Cooling Plumbing Permit Fee ............. _._._..... ....... $............. ........ ' City Business License *............... Phone:.................... Electrical Permit Fee .................. ..._...........__........._....$.........__.......... Architect: Designer: ..._................._..........___.........: Phone:.................... Mach. Ht9•/Coolg. Permit $............................. $ Engineer: Phone:.....-.............. Residential Construction Tax ..._.......................:..........$......._.............. _. ._...._......_............._............................-. Lender: . _ ....__. ..............................._................___.......... Unknown Misc. Fee ................ ...._......... _..........._ _.....................$..........._....._.. 'I certify that in the performance of the work for which this permit is nn Misc. Fee ._........_.._...._.._...._...._....f.+:. ..1.1..1.._..........$........�//.:..0�f/.` issued I shall not employ any person in any manner so as to become subject • • . ; $ f yg r,7 ky to the workman's compen tion laws of California." SIGNATURE OF • • - APPLICANT/OWNER _ .:.7.... ......._..........._........._..DATE/�:..��J.._. Environmental Status: Exempt ............ Other...._........__............... 'I certify that as the applicant I am licensed unclethe 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. (Stale 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 _JQ6JR!j[;tl,IIII burning I (We) agree to save, indemnify and keep harmless the City of Cupertino lcroachment Permit.... ....... Grant of Easement....... against liabilities, judgments, costs and expenses which may in any way 49turb, Gutter, Sidewalk, Driveway: Replace.......... Repair.......... secure against said City In con aqulca of ne granting of this permit. Sewer............ Conn. Fee $................ Water................ Meter $................ v 'SIGNATURE of Agreement for Completion of Public Works Improvements ......-........-. APPLICANT/CONTRACTOR . . .. ...._............_........ DATE/ /7. .... Plans Checked By........ Date........ Approved By..._... Date..... NOTE: When properly validate e��11his form constitutes a euilding Permit. This permit expires and becomes null and void should work not,be commenced within • • 120 days from validation dale, or should authorized construction be suspended or abandoned for a period of 120 days after work is commenced. PERMIT INSTALLATION NO. EACH FEE APPLICATION • • PLUMBING PERMIT Light Outlets......_... Switches............ Fixtures............ Receptacles....-....... •PERMIT INSTALLATION NO. EACH FEE TOTAL NUMBER (less than 1000 watts) ...__..._ $ .50 - Gas System with up to 5 outlets .................................$4.00 ............. Range...... Cooking Unit........ Oven ...... _....._ ....... 2,00 .. ............ Each additional outlet . 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,So .. ........__ Lavatory.._ Shower Pan.... Bathtub.... Sink................... 3.00............... Temporary Power Pole or Service — 100 amp .L_.,,, _.5.oD .........._. Wash. Mach..... Dishwasher.... Garb. Died..... ............... 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 1...................................................... 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 $34.50.............................. Mise. See Ord. Current) .................................................... 501-750 24.50 1751-20000 37.50.............................. q Permit Fee ............................._-........................................$ 6.00 751-1000 26.00 2001-2250 39.50.......................... ... 00 TOTAL PLUMBING PERMIT FEE (plus penalty if app. ❑) $ 1001-1250 28.50 2251-2500 42.00.............................. 1251-1500 32.00 2501-2750 49.50.............................. n APPLICATION FORHEATING/COOLING PERMIT Permit Fee...............................................$6.00 l TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.[]) $ h PERMIT INSTALLATION NO. EACH I FEE Forced Air Unit..................to 100M . ....$ 6.00- ---..... • - • - r over 100M ....._......._.......... 10.00 Comfort Cooling Unit.. to 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 Electrical . _. . ... J_. ... ��•1 P_T to 50 tort. ... .17.00 . MmIle PrhrMr 7rrg'arrt'HE'2TIng .. JZ46 W Space Heater........ Wall Heater 6.00 aLon & Energy .... __ . . - .... Flues - other than above - -._ .. - 3.00 ..as Test .......__ .. -- - Vent Fan: Kitchen... _. Bath .. ...1 3.00 Temporary Power Gas / Elect .. _ . . . _ ...... 4 6.00 Final - Electrical . Commercial Range Hood .. - -'. 4 ... --- - - - - Misc. (See Ord. Current 111 Final - Building/ Mechanical .._ __ ... __. Permit Fee _ ....... $ 6.00 Final - Design Review / Landscaping ..... . . ...... ......... TOTAL Htg./ Cool Permit Fee (plus penalty Ir a Final- Public Works ........................................................... 9 9 P Y PP• O) $ r. Sheet 2 f CITY OF CUPERTINO BUILDING PEMIT Permit No:' Address: �. Date: 42— BUILDING PROJECT IDENTIFICATION WORKERS' COMPENSATION DECLARATION Applicant's',failing Address I hereby affirm that I have a certificate of consent to self-insure, or a,certificate of Workers'Compensation Insurance,or a certified o'��� ��R2Y L(/� v thereof (Se( SW,Lab.C.,. Address of Building Policy No. Company Certified copy is hereby furnished. Owner's name A� v �i K6'Q Certified copy is filed with the county building inspection /T Cc No. depar ent o �9yA_p r-�Q( Date rt. u. _ 4Lpplicant 1�- Contractor's Name �T Contractor's Mailing Address CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE Lie. No. (This section need not be completed if the permit is for one Architect or Engineer hundred dollars ($I00) or less.) Architect's or Engineer's Address - I certify that in the performance of the work for which this permit Lie. No. is issued,I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. • LICENSED CONTRACTORS DECLARATION Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of 1 hereby affirm that I am licensed under provisions of Chapter 9 Exemption, you, should become subject to the Workers' commencing with Section 7000) of Division 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 Lic. Number � + T p�yj Date — 4— — 7-�Contractor �/1!rf / 4 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, Civ.C.). DNVNER-BUILDER DECLARATION Lender's Name 1 hereby affirm that 1 am exempt from the Contractor's Lender's Address License ' • Law for the following reason (Sec.7031.5, Business and Professions 1 certify that I have read this application and state that the above Code: Any city 0r county which requiresa permit to construct,alter, information is correct. 1 agree to comply with all city and county improve,demolish,or repair any structure,prior to its issuance,also ordinances and state laws relating to building construction, and requires the applicant for such permit to file a signed statement that hereby authorize representatives of this county to enter upon the he is licensed pursuant to the provisions of the Contractor's License above-mentioned property for inspection purposes. Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) or that he is exempt therefrom and Signature of Applicant or Agent pate the basis for the alleged exemption. Any violation of Section 7031.3 - by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500).): "OWNER-BUILDER ❑ 1,as owner of the property,or my employees with wages as VER]FICATION their sole compensation,will do the work,and the structure is not "Attention Pro' rt 0%'rer. intended or offered for sale (Sec. 7044, Business and Professions Pe Y Code: The Contractor's License Lain does not apply to an owner of An-'owner.builder' building permit has been applied for in property who builds or improves thereon,and who does such work your note and bearing your signature. himself or through his own employees, provided that such "Please complete and return this information in the envelope provided at your earliest opportunity to avoid unnecessary delay improvements or im are not intended or offered for sale If,however,the in processing and issuing your budding per^it.No building permit building it improvhave t is sold within one year of he did not b the will be issued until this verification is received. owner-builder will have the burden of proving that he did not build 1. 1 personally plan to provide the major labor and materials for proposeproperty improvement or improve for the purpose of sale.). construction of the d ro F-11,as owner of the property,am exclusively contracting with P P (yes or no) licensed contractors to construct the project (Sec.7044,Business and 2 I (have/have not) signed an application for a Professions Code: The Contractor's License Law does not apply to SnopP 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 S. I havecontracted with the following person(firm) to provide the Contractor's License Law.). the proposed construction:Name rca n1 am exempt under Sec. , B.&P.C. for this Address City Phone Contractors License No. Date Owner 4. 1 plan to provide portions of the work, but 1 have hired the following person to coordinate,supervise, and provide the major work- Name Address City Phone Contractors License No. 5. 1 will provide some of the work but 1 have contracted(hired) the following persons to provide the work indicated: Name Address Phone Type of Work - Signed: Property owner Social Security number Date: L