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1602 (2) CITY OF CUPERTINO APPLICATION FOR RESIDENTIAL BUILDING PERMIT t7 A1r) PERMIT NUMBER Q Z AND CERTIFICATE • . APPLICANT CERTIFICATE OF OCCUPANCY. BUILDING INSPECTION DIVISION STREET ADDRESS OF P JECT; a..4..3.....GPm.�x.t.A .e...._.. �_................. DEPARTMENT USE ONLY Legal Description: Tract....................... Block............ Lot...................... Plana Received By .._..... Description of Work: ......_........._.................... _.. .......... .._............. vey ..................................._Date .........._..--....... _ _ ...... REO .: Pena.:.. Survey.... Coles: Struc..... Energy.... Elect..... Mach.... tat Struct. Improvement on Parcel:Yes.... No... Area of Bldg............... Plans Checked By.................._.._................ ......Date Separate Structure__........ or Addition/Alteration to Exist. Bldg.........., Application Approved By........... ...............Date //­7:/­`44-_,W.. No. of Stories...........:.... Use of Building ............................ Validated By..............................................C?:5.........Date ........................ Valuation of�rojec : $.. .................. ... ..... ..........._._._......_..........-..._...._...................... Compensation Certificate Verified By ....... ... Date ..-._.. ..... Owner: ...... C1�.. MQA..M._....__.............._........_ Phone:.................... • • • $ Contractor: City Bus. Lia #-.............. . . Contractor's Address: ..._.... . .......................... Pp?e:.................... Permit Fee (plus penalty if applicable) Contractor - Electrical: $....,�".,.Lyd7c/f.__....P�..:................ Plan Check Fee (less deposit of$.......... Rct. #.........J$................. City Business License #_.........._...... Phone:.4j/.4dYi Energy Plan Check Fee (Dep. of $........ Pct. #.......-) $...................... Plumbing: .._......................................_......._.............._............... Strong Motion Fee ..........................................................$....................... - City Business License #.._........... .... Phone:.................... Plumbing Permit Fee $. Heating and Cooling ..:_ ........................___............................ Electrical Permit Fee ..._.............................__..........._...$./..e�.,:.] ...... City Business License #.................... Phone:.................... Mach. Htg./Coolg. Permit $.......... $....................... Architect/Designer: ............._.._......'.:_.._..._... ....... Phone:..........:......... Engineer: Residential Construction Tax . ......_ ....._... .... -............ ---- - .--.. Phone:.-............ . ............ Lender' . .. .... Misc. Fee ........._................. ............._......._...._...$................-..... ... .... _ ...... ... . ...._......._. ❑ Unknown 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 • $ to the workman's compensation laws of California." RE OF �^ '(�y I —/y ZONING • APPLICANT/OWNER .9.....-"WnA_............ DATE. 1....... l.V Environmental Status: Exempt............ Other.__.........._...................... SIGNATURE certify that as the applicant I am licensed unde the prov'slons of the Design Review Approval: Bldg. ........... Site ........_.. Sign ......._... Contractors License Law and further that my Licens. No.d�:1..$1.FL_... Use Zone ............ P.D. Conditions ...__.............._.._..._..........._._......_... in Classification ......G,-,10...._....._...... is in full force and effect: or Cond. Use Permit #............ Variance #..... Parking Spaces...........- - b 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 1 have read this application and state that the above Is • , • correct and agree to comply with all City ordinances and State Laws regulating " buildmg. ir I (we) agree to save, indemnify and keep harmless the City of Cupertino Cf08ChmBnt Permit........._............ Grant of Easement..............._....... against liabilities, judgments. costs and expenses which may in any way Urb, Gutter, Sidewalk, Driveway: Replace.......... Repair._....... accure against said City In consequence of the granting of this permit." 11 Sewer........_.. Conn, Fee $................ Water. .............. Meter $................ SIGNATURE OF / Agreement for Completion Of Public Works Improvements ..............._. APPLICANT/CONTRACTOR/7/i/Zlwk!1d�y.. (/'L DATE II'�. .�.O.a. 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 bays from validation date, or should authorized constru`ellon be suspended or abandoned for a period of 120 days after work is commenced. PERMIT INSTALLATION NO. EACH FEE Light Outlets.... APPLICATION FOR..... Switches. a...... Fixtures.......el. Receptacles.....7.... 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 ............................................. 1.00............... 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 ...._.._......3.50 .....__..... 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..................... ............. Mlac. (bee Ord. current 1Vacuum........... ...................................: . ... .........................-..................................3.50.............. New Rasitlen[lal OF_pancles Flat Rate Interceptor reakerWater Softener........ 4.00. 0-500 sq. ft. $22.00 1501-1750 $34.50............................... ................ Plumbing Piping without fixtures ...................................4.00_,..........-„ ............. .. ................................ Misc. (See Ord. Current) ......... ........... 501-750 24.60 1757-20000 37.50.............................. , 751-1000 26.00 2001-225C 39.50.............................. Permit Fee ......................................................................... $8.00 1001-1250 28.50 2261-2600 42.00.............................. TOTAL PLUMBING PERMIT FEE (plus penalty If app.0) $ 1251-1600 32.00 2501-2750 49.50.............................. APPLICATION HEATING/COOLING PERMIT Permit Fee...............................................$6.00 TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.p) $42 b-U PERMIT'INSTALLATION NO. EACH IFEE — INSPECTION RECORD Forced Air Unit..............._to 100M ..............................$ 6.00............... over100M ....................I..... 10.00.. Comfort Cooling Unit .to 3 ton/HP ........................... 6.00............... Forme / Foundation_............. ...__..._ BY:__._ . ....:. Date:................ .....to 15 ton/HP..................._.... 9.50.............. Plumbing Ground Work ...-.-. ........_.... j.. .. ...._._....._ ......................._. to 30 tort...........................12.00. ............ . Rough Electrical ........... ........__...........�..__....,......._.... ... ......... to 50 ton/HP...........................17.00.. ........... `rame - Plumbing and Heating .......... ................_...._. ._...._.............. ... Space Heater........ Wall Heater ...................................� 8.00 sulTest .. Energy..._........._............... ...:_................_. ..._..._.............._. Flues - other than above .............._..._.....................,.... 3.00............. as Test ._ . .c - - . . .... Vent Fan: Kitchen. . Bath ...............................- .. 3.00 . Temporary Power Gas / Elect ���`` ... ` -- -- Commercial Range Hood ..... ,,, ,l, 6.00 Final - Electrical .. � � ` .............. "" _.. - -- Misc. (See Ord Current ._. Final - Building/ Mechanical .. - � -'*' '����' ** '*��� "" - ""- Permit Fee $ 6.00 Final - Design Review / Landscaping _ _. , -"- TOTAL Htg. , ppenalty pp. ❑ Final-Public Works / CoolgPermit Fee (plus If a ) $........................................................... ' 4'• Sliect 2 1 CITY OF CUPERTINO BUILDING PERt4IT 4 Permit No• Address: •774'3 Cdj3p;Aae C7- . * Date: /1 - 79- 6!0 BUILDING PROJECT IDENTIFICATION WORKERS'COMPENSATION DECLARATION Applicant's Mailing Address I hereby affirm that I have a certificate of consent to self-insure, or a certificate of\Porkers'Compensation Insurance,or a certified (77 L) 3 CA R IJOt•CT copy thereof (Sec 50(1,Lab.C.j. Address of Building Policy No. Company Certified copy is hereby furnished. Owner's name P'r1'-�--� Certified copy is filed with the caunh• building inspection / Telephone No. a 4 3 -- 77/ department or county department. / Date Applicant Contractor's Name ANfrZ fATcI') Tlf r. ST Contractor's Mailing Address �b'44LidC_4Ct]. I RCERTIFICATE OF EXEMPTION FROM WORKERS' Ate/7cce -'G• Y9'71107 COMPENSATION INSURANCE Li,.No, C f0 -1.7 0 N (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 AddressI certify that in the performance of the work for which this permit Lic. No. is issued,l shall not employ any person in any manner suits to become subjegt to the R'orkers'Com peq son Laws of liforn,ty LICENSED CONTRACTORS DECLARATION Date/ Is- U Applicantrnyh{ NOTICE TO APPLICANT: If, after making this Certificate of I hereby affirm that I am licensed under provisions of Chapter 9 X 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. /C License Class f'- )n Lie. \umber 'g Date J/-ret- ka Contractor � CONSTRUCTION LENDING AGENCY I 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 hereby affirm that I am exempt from the Contractor's License Lender's Address Law for the following reason (Sec.7031.5,Business and Professions 1 certify that 1 have read this application and state that the above Code: Any city or county which requires permit to construct,alter, information is correct. I 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 fife 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 P Signature of Applicant or Agent pate the basis for the alleged exemption.Any violation of Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1,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 name 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 are not im ended or offered for sale.if,however.the {n ocewing and issuing your budding permit.No building permit building or improvement is sold within one year of completion,the will be issued unti11h0,veri sea received. or improve for will have the burden of proving that he did not build 1. 1 personally plan to provide the mal bor and materials for or improve for the purpose of sale.). • construction of the proposed properly improvement (yes or no ❑ I,as owner of the property,am exclusively contracting with - � ) licensed contractors to construct the project (Sec.7044,Business and y L (have/have not) si d an application for a Professions Code: The Contractor's License Law does not apply to gnopP an owner of properly who builds or improves thereon, and %he building permit for the proposed work contracts for such projects with a contractor(s) licensed pursuant to a I have contracted with the following parson(firm)to provide the Contractor's License Law.), the proposed construction:Name roman l am exempt under See. B.hP.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: I -