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1348 (2) CITY OF CUPERTINO -- --.• �} APPLICATION FOR RESIDENTIAL BUILDING PERMIT PERMIT NUMBER 3 AND FOR APPLICANT TO FILL IN CERTIFICATE AND OCCUPANCY ` BUILDING INSPECTION DIVISION S ��T ADPUSS OF PROJECT: 7'.C6(. ..K • . • e Legal• ascription; Tract....................... Blocck............... I,pt....... Plane Received By Description of Work: - ,e-1�F '/+�-D...�•4 I . ..... y.......................................... ..Date ......................... ............................................................................................................. ....... REQ.: Plans.... Survey.... Calcs: Struc..... Energy.... Elect..... Mach.... 1st Struct. Improvement on Parcel: Yes.... No.... Area of Bldg............... Plans Checked By,,,...............,L .. Date ........... Separate Structure............ or Addition/AI ation to Exist. BJ�9,�...... 1 Application ApproBy...:...[.'�.:�..,......._..._.......Date .....`.� ../d.....:.. No. of Stories..../......... Usg of Buildin9�Yi +EA vo.'K y..t�1QS/f/ Validated By..............................................................Date .......-.............. Valuation Project: $... Q�. .7] ................................... Compensation Certificate Verified B .. Date ............. .. ---- Phone:.................... P y --.........._.. . .......... Owner: .... -. I:e' � $ yo3/ �Z Contractor: . $//!7'.. .!� ....I.Pity Bus. Lic. #'............. • • • • • Contractor's Address: //fQ..� •C�oT % Phone Z1i.3'7k..3 Permit Fee (Plus penalty If applicable) ........................$....,3.x...(/'QContractor - Electrical: .....:....................................................................... Plan Check Fee (less deposit of$.......... Rct. #..........)$_.................... City Business License #.................... Phone:.................... Energy Plan Check Fee (Dep. of $........ Rct. #........)$....................... Plumbing: ........................................................................ ............ ......................$...........A.. ...... ............... Strong Motion Fee ....._..............._...........- `CD City Business License #.................... Phone:..... Heating and Cooling ........... • ....................................................... Plumbing Permit Fee ................._................. ...... ....................... . City Business License #.._ ............... Phone:..........'.......... Electrical Permit Fee ......................................................$.........,............. Architect/Designer: Mach. Htg./Coolg. Permit $............................. $........... .................................................. Phone;.... ............ Engineer: ._ ............_... Phone:.............own ResidentialConstruction Tax ........................................$....................... _._................_....................... Misc. Fee $....... ............... Lender: ...certify that .....the perf..............of . .. hit j his per own .................... ...._..._..................................................._........ ^I cerlil that in the ..... .. Y penny person of the work for which eco penult is Misc. Fee ........................................................................$..... .x0.'0..... issued I shall not employ any parson in any manner so as to become subject • $'3 7., O to the workman's compensation laws of California." SIGNATURE OF • • APPLICANT/OWNER .............a................_...................................�. DATE........................ Environmental Status: Exempt ............ Other....................................... .. 'I certify that as the applicant I am licensed uncle' the prro�oyylslons of thgg,, Design Review Approval: Bldg. ............ Site ............ Sign —......... Cordractors Licensa•t a- �pn further that my Licens. No. Use Zone ......._... P.D. Conditions ................. in Classification C .... /........._.I—— is In full force and effect: or Cord. Use Permit ...... Variance #.._.._.... Parking Spaces............ I certify that I am exempt from the "Licensed Required" provisions of the Contractors License Law. (State basis of exemption.) Approved By........_................................................ Date ........................... "I hmeby 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 • • building. • I IWe) agree to save, incirfallyantl keep hArmin t Ci y of Cupertino croachmert Permit........................ Grant of Easement........................ against liabilities titles, lutl anis costa and•e x pe se hit may In way rb, Gutter, Sidewalk, Driveway: Replace.......... Repair.......... .acture against said c y In as uence of a ntin of this permit." -Sewer............ Conn. Fee $................ Water................ Meter $................ SIGNATURE OF Agreement for Completion of Public Works Improvements .................. APPLICANT/CONTRAC DATE Plans Checked By........ Date........ Approved By........ Date.................... . NOTE: When properly alitlelad this form constitutes s Building Permit. This permit expires and becomes null and void should work not.be commenced within APPLICATION • 120 days Irom validation date, or should authorized construction be suspended or abandoned for a period of 120 days alter work is commenced. PERMIT INSTALLATION NO. EACH FEE APPLICATION FOR 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 ......I...... li Range........ Cooking Unit........ Oven............ ................ 2.00 .............. Each additional outlet ............................................. 1.00............... Dryer........ Garb. Dis Dishwasher ............ .....I-— Water System Installation, Alt. or Repair) . 4.00............... i 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............... —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 I...................................................... 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 37.60.............................. Permit Fee .................:................................. .... 761-1000 26.00 2001-225C 39.60.............................. y p• $8.00 1001-1250 28.60 2251-2500 42.00.............................. TOTAL PLUMBING PERMIT FEE (plus penalty if app. "7_�) _ 1251-1500 32.00 2501-2750 49.50........I..................... APPLICATION FOR HEATING/COOLING PERI PermitFee...............................................$8.00 TOTAL ELECTRICAL PERMIT FEE (Plus penalty If app.0) $ PERMIT INSTALLATION 11NO. EACH FEE • Forced Air Unit..................to 100M ..............................$8.00............... • - • - r over 100M........................ . 10.00.. ........... Comfort Cooling Unit......to 3 ton/HP ......................... .. 6.00 . Forma / Foundation ............... .............. By:.._.... ....... . Date:....,........... ... ........... to 15 ton/HP......................... 9.50.............. Plumbing Ground Work .............. ...... ..._.........._..........___......... to 30ton/HP........................ ..12.00. ............ Rough Electrical ..._............................... ... ......... .. .................._..........._... to 50 ton/HP............................17.00.. ........... _ •me - Plumbing and Heating ................................... ........................... 6.00.. Space Heater........ Wall Heater ................................... ............ dation & Energy............................... ......................... ........................... Flues - other than above .............................................I.. 3.00.............. sTest ............... .................._..... ......................_.....'... ........._.._........ Vent Fan; Kitchen........ Bath............................. ............ 3.00............... Temporary Power Gas / Elect. . ........ .......I.........................................- Commercial Range Hood 8.00, Final - Electrical ....:.........ical.........-...... ......................... ........................... Misc. (See Ord. Current............................................... ......... Final - Building/ Mechanical ...................................... .......................... Permit Fee .......................... .. 8.00 Final - Design Review Landscaping . . "-' .' ' "'.""'� "�""'...-""" - --- .-.-.--.---...... TOTAL Htg./ Coolg. Permit Fee (plus penalty If app. p) $ Final-Public Works ........................................................... $beet 2 CITY OF CUPERTINO BUILDING PERf4IT %116. Permit No• /3 Address: ,� �, g • Date:_ //D�Tt-r'f BUILDING PROJECT IDENTIFICATION WORKERS'COMPENSATION DECLARATION Applicant's Mailing Address /�lM STr I hereby affirm that I have a certificate c:consent to self-insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof (Sec S00,Lab.C.'t. Address of Building Policy No. Company P Y ertified copy is hereby furnished. Owner's name S Certified copy is filed w' he county buildi spec ' n Telephone No. depart eln nt or county__ de tment C®/ Date��APPlicant Contractors Name Contractors Mailing Address f/ CERTIFICATE OF EXEMPTION FROM WORKERS' .!5,ft2,22seCOMPENSATION INSURANCE Lc.No. i'fJ-ZZQ25 (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,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 I hereby affirm that I am licensed underrovisions of Chapter 9 p s Exemption, you, should become subject to the Workers' with Section 7000) of Division 3 of the Business and Compensation provisions of the Labor Code,.you must forthwith Professions Code, n license is in full force and effect. comply with such provisions or this permit shall be deemed revoked. License Cl as Lit. Number'_�3 Date —/O— Contractor �— 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 herebv arm that 1 am exempt from the Contractors License Lender's Address affirm Law for the following reason (See.7031.3, Business and Professions 1 certify that 1 have read this application and state that the above Code: Anv city or county which requires a permit to construct.alter, information is correct. I agree to comply with all city and county mprove,demolish,or repair any structure,prior to its issuance,also ordinances and state laws relating to building construction, and equires 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 the basis for the alleged exemption.Any violation of Section 7031.3 Signature of Applicant or Agent p,te by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (S300).): I,as owner of the property,or my employees with wages as '*OWNER-BUILDER VERIFICATION their sole compensation, will do the work,and the structure is not intended or offered for sale (Sec. 7044, Business and Professions "Attention Property Owner. Code: The Contractor's License Law 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 mme and bearing your signature. himself or through his own employees, provided that such "Please complete and return this information in the envelope improvements are not intended or offered for sale. If,however,the provided at your earliest opportunity to avoid unnecessary delay building or improvement is sold within one year of completion,the 'hi processing and issuing your budding permit..No building permit owner-builder will have the burden of proving that he did not build will be issued until this verification is received. or improve for the purpose of sale.). 1. 1 personally plan to provide the major labor and materials for ❑ 1,as owner of the property,am exclusively contracting with construction of the proposed property 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 - '1 F (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 a I have contracted with the following person(firm)to provide the Contractor's License Law.), the proposed construction: ❑ 1 am exempt under Sec. , B.h P.C. for this Name reason Address City Dain Owner Phone Contractors License No, 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. & 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 a , Signed: Property owner Serial Security number Date.