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1151CITY OF CUPERTINO APPLICATION FOR RESIDENTIAL BUILDING PERMIT AND CERTIFICATE OF OCCUPANCY BUILDING INSPECTION DIVISION Plans Received By ..................... ............................... Date ......................... REO.: Plana.... Survey.... Calcs: Struc..... Energy.... Elect..... Mach.... Plans Checked By ............................ .......:..... Date ........../.............. Application Approved By______. .,..� ................. Date ...�%.rLd��d ValidatedBy ......................... ............................ ........ Date ........_......... Compensation Certificate Verified By ................. Date ...... ..- ............... • • • MIIIIII $ Permit Fee (plus penalty if applicable) ......... .. ..... ....... $/0...... Plan Check Fee (less deposit of $....':..;. -Rct:: #..........) $....... Energy Plan Check Fee (Dep. of $........ Rct. #........) $ ............... .. Strong Motion Fee ....... ....._-.:,` ... ........:.:..................._ $ ........ ._I S`O.. Plumbing Permit Fee ...... ....... ......................... .......... $....................... Electrical Permit Fee ....................... ............................... $....................... Mach. Htg. /Coolg. Permit $,c ...... - .... d ... ).1......... $......__..._........ Residential Construction Tax .................... I ... ................ $....................... Misc. Fee ........................................ ............................... $....../ ... Misc. Fee ......................................... ............................... $......Y... OZ).. ZONING REQUIREMENTS Environmental Status: Exempt ............ Other ......... ............................... Design Review Approval: Bldg ............. Site ............ Sign ............ Use Zone ............ P.D. Conditions ............................. ............................... Cord. Use Permit #............ Variance #............ Parking Spaces............ ApprovedBy ......... ................. ....................... .... Date .................... t Permit ........................ Grant of Easement ............. ........... rb, Gutter, Sidewalk, Driveway: Replace.......... Repair.......... ewer............ Conn. Fee $ ................ Water................ Meter $................ Agreement for Completion of Public Works Improvements .__ ............. Plans Checked By........ Date........ Approved By........ Date .... ...... ....._.. PERMIT INSTALLATION NO. EACH FEE Light Outlets............ Switches............ Description of Work ...._. ..:..._.........._ ............. ._......... _............. .......... ........ .......... _..._.._.�'j,c.e_eh. 0!� ._.. ...._.._............... ...... .. 1st Struct. Improvement on Parcel: Yes.... No ... Area of Bldg ............... Separate Structure............ or Addition/ Alteration to Exist. Bldg........... Fixtures............ Receptacles............ Valuation of Project: $, ........... .............. _ ..... ..............._............ Owner: . ... .... .. ... ._...... ..._............ ........_............._... Phone:...._. ...... ....... Contractor: ..... ......... ...... .... . .......... ........... ...... City Bus. Lic. # .............. TOTAL NUMBER (less than 1000 watts) ............ Contractor - Electrical: ............. _............._...._.... ........._........___._........ $ ,50 .... . Range........ Cooking Unit_._... Oven.. .......... ... _ .. ...... 2.00 .............. Architect/ Designer: .. ..... .... .. .. ................... _..... Phone:................... Dryer........ Garb. Disp ..... Dishwasher ...... ..... ......... Lender: .. ..... ...... .. ... .........._. ..... ............................. .. E) Unknown 2.00 _ ............ MOTORS: 1 HP or less ........... ... ......... ..._ ...... ....... .... . 2.00 .. ........_.. Greater than 1 HP not more than 5 HP ....... ._..... 3.50 .. ....._._.. Temporary Power Pole or Service — 100 amp .........5.00 b lifwg. u .. .... _...... — 200 amp ....... SIGNATURE OF 7.00 .............. NOTE: When properly validated this form constitutes a Building Permit. This TimeClock ....... ..._ ...... ....._ ...... .._........._..__.....__. ...._t 1.50........_... -. Misc. ( nee Ord. current I ................... ............................... Gas System with up to 5 outlets ..................... ............$4.00.............. . . New Residential Occupancies Flat ate 0-500 sq. ft. $22.00 1501 -1750 $ 34, 50 .............................. 501 -750 24.60 1751 -20000 37. 60 .............................. 751 -1000 26.00 2001 -2250 39. 50 .............................. 1001 -1250 28.60 2251 -2500 42. 00 .............................. 1251 -1500 32.00 2501 -2750 49. 50 .............................. PermitFee ..................... ..........................$8.00 TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.C)) $ INSPECTION • -. Forms / Foundation ........ ...,.. ... ... .. _..I By: ..... Date:..._........... Plumbing Ground Work ....... . i.... .... .._ ....... ough Electrical ame - Plumbing and Heating .I .. ulatlon 8 Energy ............................. ................ ......_..�.......... ................ aas Test ......................... ....... ....... .t. ........ _.........! .__..... _..... Temporary Power Gas / Elect- ... .... . 1{ 1{ 1{........... ........... ...... ............... Final- Electrical ..............._..._ ._......... L..._................. ..,1........................... Final - Building /Mechanical _ ................. —............. ......................... Final - Design Review ..................... Final- Public Works ............................ ............................... PERMIT NUMBER FOR APPLICANT TO FILL IN STREET DSS OF ROJECT: 1.1 A �.RE y. /.._.._...ar.i ....(�unye.n... ......... Legal Description: Tract.-... .................. . Block............ Lot...................... Description of Work ...._. ..:..._.........._ ............. ._......... _............. .......... ........ .......... _..._.._.�'j,c.e_eh. 0!� ._.. ...._.._............... ...... .. 1st Struct. Improvement on Parcel: Yes.... No ... Area of Bldg ............... Separate Structure............ or Addition/ Alteration to Exist. Bldg........... No. of Stories ................ Use of Building ....... ....-...... ... .............. ........... ... Valuation of Project: $, ........... .............. _ ..... ..............._............ Owner: . ... .... .. ... ._...... ..._............ ........_............._... Phone:...._. ...... ....... Contractor: ..... ......... ...... .... . .......... ........... ...... City Bus. Lic. # .............. Contractors Address:...... _ ........ .......... .... .......... .... Phone %................. .. Contractor - Electrical: ............. _............._...._.... ........._........___._........ City Business License #.... ......... ._... Phone: .................... Plumbing:..... City Business License # ......... ...__.... Phone: ... ....... Heating and Cooling ..... ................... ___ ........ ....... .__.............. City Business License # .................... Phone:.................... Architect/ Designer: .. ..... .... .. .. ................... _..... Phone:................... Engineer: .........._ ........... ....... ........ .._................... Phone: .... ............... Lender: .. ..... ...... .. ... .........._. ..... ............................. .. E) Unknown '9 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 workman' mpensation laws of California7"� SIGNATURE OF y� n ;V vs � ' �/� APPLICANT /OWNEih}.. •!(,LCl/ s31o,arC/,,., DATE7,- V.. ".4Jt,.� "I certify that as the applicant I am liconsed uncle the provisions of the Contractors License Law and further that my Users, No. _ ......................... in Classification ....... ._ .......... ..._ _.......... is.in full force and effect: or I certify that I am exempt from the 'Licensed Required" provisions of the Contractors License Law. (State basis of exemption.) I horeby acknowledge that I have read this application and state that the above Is - trect and agree to comply with all City Ordinances and State Laws regulating b lifwg. u I (Wei agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way occurs against said City in consequence of the granting of this permit." SIGNATURE OF APPLICANT /CONTRACTOR . ... ... ... .... ....... _ .. ............... .... ..... _.... DATE ........................ NOTE: When properly validated this form constitutes a Building Permit. This permit expires and becomes null and vold should work not be Commenced within 120 days from validation dab, or should authorized construction be suspended or abandoned for a period of 120 days alter work is commenced L. APPLICATION FOR PLUMBING PFRMIT PERMIT INSTALLATION NO. Jill EACH I FEE Gas System with up to 5 outlets ..................... ............$4.00.............. Each additional outlet .............. ............................... 1.00............... Water System (Installation, Alt. or Repair) ................. 4.00............... Water Closet.... Water Heater.... Ld. Tray ..................... 4.00. ............. Lavatory.... Shower Pan.... Bathtub.... Sink ................... 3.00............... Wash. Mach..... Dishwasher.... Garb. Disp .................... 3.00............... Sewer..__ .. .......................... ....... .... ....................... ........ .. 8.00............... Lawn Sprinkler Sys. $5.00 Ea. add Sys. $2.00 ..................... ............. VacuumBreakers ............. ............................... . .............3.50.............. Interceptor........ Water Softener ....................... ..............4.00............. Plumbing Piping without fixtures ....................... ............4.00............... Misc. (See Ord. Current) ..................... ............................... PermitFee ........................ ............. ............................... $ 6.00 TOTAL PLUMBING PERMIT FEE (plus penalty it app. ]) $ APPLICATION •• •• LING PERMIF PERMIT INSTALLATION 1 NO. EACH I FEE Forced Air Unit.................. to 100M ..................... ....... .$ 8 . .00............... over100M ..­ ..................... . 10.00 .. ........... Comfort Cooling Unit..... to 3 ton /HP ................. ........�.. 6.00.............. to 15 ton /HP ......................... 9.50 .. ............ to 30 tort ................ ...... 12.00. ......... to 501on /HP .. .... . 17.00.. .......... h.. Space Heater........ Well Heater ........................... .......1 8.00 ....... .- -... Flues - other than above ............. ............................... ).. 3.00 Vent Fan: Kitchen........ Bath ............................... ........ .. 3.00............... Commercial Range Hood ............ ..... .........__..... ...... 8,00............... Misc. (See Ord. Current ..... ...... ........... . ............ .... ........ ... .......... .............. PermitFee .. ..................... ..._......_. .........__..........._-....... $ 8.00 TOTAL Htg./ Coolg. Permit Fee (plus penalty if app. ❑) $