1719 CITY OF CUPERTIN
APPLICATION FOR RESIDENTIAL BUILDING PERMIT PERMIT NUMB
• AND FOR APPLICANT TO FILL IN
CERTIFICATE OF OCCUPANCY
BUILDING INSPECTION DIVISION STREET ADDR7SS OF PROJECT:
al':�' . "T' "M . ZI,
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Legal Description: Tract, ... Block............ Lot_._...............
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Plana Received By.....................11�`7.................. Date .... De scription of Work: .AL...._....._.._..._....._...............................
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......St� ........................4;>004. - . .............
REQ.: Plans.... Survey.... CaIcs: Struc..... Energy.... Elect..... .Mach.... 1st lucl. Improvement on Parcel:Yes.... No,. Area of Bldg...............
7
Plans Chocked By..........................01......4�*�... Dal Separate Structure........_... or Addition/Alteration to Exist. Bldg...........
Cat: �.. .....
Application Approved By.......................... No. of Stories................ Use of Building .................. ...............................
Validated By.............................................................Date ................. Valuation of Project, $
Compensation Certificate Verified By __............. Date ............. ........... Owner: Phone:-..-..
Contractor: City Bus. Lic. #
$ 3,S-6-0 Contractor's Address 1-2-7-1... dATO&A........... Phone
ractor - Electrical: ........_.................
Permit Fee (plus penalty it applicable) ........................ Con: All�m
Plan Check Fee (less deposit of$.......... Rot. #..........)$.......................
City Business License # ...... Phone:....................
Energy Plan ChecClifye ape@UVERTMORCL #.".."') F. --- Plumbing: ....._............ ...... ............................................
-0 City Business License #................... Phone:....................
Strong Motion Fee ....................................... ..........$..... .. 1
V�6.0' Heating and Cooling ......... ................
Plumbing Permit F --- $ City Business License #.................... Phone:....................
Electrical Permit FeD E.C' .0 ................$
. Architect/Designer; ............ ...............___.... Phone:....................
Mach. Htg./Cocilg. Permit $............................. $....................... Engineer: . .. ....... ..............____.............. Phone:......
Residential Construction - , " $..........
. . ................ Lender: ........ ......... [:)....... ❑ Unknown
Misc. Fee ........ ..... ... PAID,-.....I......... . .... $
Misc. Fee ................................................... ........... 'I 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
'a theworkman'sU I* laws of California."
�ioijr-• ' 'a'
SIGNATURE OF
4l
APPLICANT) e
'OWNER ..... DATE.J
Environmental Status: Exempt............ Other....................................... 1 certtly that ns the applies am "..a d d the 3�141aas (3.,?f the
s'" up
Design Review Approval: Bldg. -........ Site ............ Sign ...... Contractors License Law and further that my Utters, No
. z
Use Zone ............ P.D. Conditions ....... .......... in Classification ... ..... is in full force an so: or
Cord. Use Permit +y............ Variance +y......._... Parking Spaces............ I certify that I am exempt from the 'Licensed Required" provisions of the
Approved By. .............................. ................... Data ..................... Contractors License Law. (State 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
bu;udurug.
I (We) agree to save, indemnity and keep harmless the City of Cupertino
croachment Permit....-............... Grant of Easement....._.._..._......... against liabilities, judgments, costs and expenses which may In any way
Ourb, Gutter, Sidewalk, Driveway: Replace.......... Repair.......... secure against said City in consequence of the granting of this permit."
Sewer............ Conn. Fee $................ Water................ Meter $................ SIGNATURE OF
Agreement for Completion of Public Works Improvements ......._........ APPL ICA NT/CONTRACTOR ... DATE /Z-150.6.D.
Plans Checked By........ Date........ Approved By........ Date......... ......... NOTE- When property validated this fdrdh constitutes a Building Permit. This
permit expires and becomes null and void should work not be commenced within
:14;V111 1 120 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............ Switches............
Fixtures............ Receptacles............ I't:HMII INSTALLATION NO. EACH FEE
TOTAL NUMBER (less than 1000 watts) ............ $ .60 .............. Gas System with up to 5 outlets .................................$4.00. ..............
Range........ Cooking Unit......-. Oven............ ............_. 2.00 ___....... Each additional outlet --------------------------_---------------- 1.00...............
Dryer........ Garb. Dap......... 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. 14� Lawn Sprinkler Sys. $5.00 Ea. add Sys. $2.00.................... ..............
Misc. (see Ord. current)...................................................... Vacuum Breakers ... ...... ......_............... ...........
Now Residential occupancies Flat Rate Interceptor........ Water Softener........ ..........................�::,4:,000
Plumbing Piping without fixtures ...................................a.00....I .....
0-500 sq. ft. $22.00 1501-1750 $34.60.............................. Misc. (See Ord. Current) ....................................................
501-760 24.60 1751-20000 37.60.............................. Permit Fee ..........................._......... - .. -..................... $6.00
751-1000 26.00 2001-2250 39.50......................... TOTAL PLUMBING PERMIT FEE (plus penalty If app.0) $,,62 P`rd
1001-1250 28.60 2251-2500 42.00.........................
1251-1600 32.00 2601-2760 49.50.................:............ APPLICATION FOR HEATING/COOLING PERMIT
. Permit Fee...............................................$6.00
TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.0) $ PERMIT INSTALLATION NO. EACH FEE
7-jv Forced Air Unit..................to 100M ..............................$8.00:..............
INSPECTION RECORD over 100M ....................... . 10.00.. ...........
Comfort Cooling Unit......to 3 ton/HP ......................... .. 6.00..... ...........
Forms / Foundation ... ....... ............_.. .1 By:_.-I ....... Date:.........._.... to 15 tort................. ...... . 9.50...............
Plumbing Ground Work . .................... .... ..-........ ............. to 30 ton/HP.....................:.. ...12.00.. ............
Rough Electrical ........ . ........ ........._......... to 50 ton/HP........................ ...17.00.. ...........
0trite - Plumbing and Heating ..... ....-....... ....I...............__ Space Heater........ Wall Heater .................................. 6.00...............
ulation & Energy................. ........ -............ ........ . ......................... Flues - other than above ..................__..................._ .. 3.00..............
1a's Test .................__.... ... ... .._.....__.........L......._.._.........-. Vent Fan: Kitchen........ Bath .................... ...._I
_J.. 3.00...............
Temporary Power Gas / Elect. ........ .. ................. ..... ....... Commercial Range Hood ...........I....... 6.00.............
Misc.Final - Electrical ............. ..... ....___............. .................... 'IOrd. Current..................................._......... . ......- ............
Final - Building I Mechanical ........-, __ ._.......... ___......... (See Permit Fee ............. ............... ......... ................... $ 6.00
Final - Design Review / Landscaping . .... ............. ............................ TOTAL Htg./ Coolg. Permit Fee (plus penalty if app. CI) $
Final-Public Works ...........................................................