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1886 (2) CITY. Of, 1 CITY OF CUPERTINO rrCCQQ APPLICATION FOR RESIDENTIAL BUILDING PEF&MP O PERMIT NUMBER AND • . APPLICANTs CERTIFICATE OF OCCUPANCY pA -FILL IN BUILDING INSPECTION DIVISION STREET ADDRESS OF PROJECT: ...—........ 750.7..De...La-Rarge-Dr...................... ..... • • • • • Legal Description: Tract....____. - . Block............ Lot .. Description of Work: .Rero.of...Res................................................... PlansReceived By....................................................Date ......................... REO.: Plans.... Survey.... Calcs: Struc..... Energy.... Elect..... Mach.... 1st Struct. Improvement on Parcel:Yes.... No.... Area of Bldg............... Plans Checked By............................ ... Date .... ... ' Separate Structure...... or Addition/Alteration to Exist. Bldg........... Application Approved By.....PP PP ......_._. ...L.p............Date ...... ........ .t'1{ No. of Stories................ Use o Building .................. ...................... Validated By_._......_......._............__......_................Date ..........._.._.__.. Valuation of Project: $..3,3b0......... ......................... ...................._...__. Compensation Certificate Verified By ...... ......... Date .... ... Owner.<,.. (.Q. W.!. 5 ..._. . Phone:.......... ...... Coniractor:x RH .Ma +' .... .. City Bus Lic. # ......MKTTPIX ... • • • - • s3,360 Contractor's Address: X.Qg1 -olrltS $T,_,,,,, phone +5�.$ 1%q Permit Fee (plus penalty f applicable) 28 00 Contractor - Electrical: .......... ..............................._....._._.. lP P e PP ..._.#...........$.......-r._......._.. Plan Check Fee (less deposit of$.......... Rct. #..._.....)$_...._r.............. City Business License *..__.............. Phone:.................... Energy Plan Check Fee (Dep. of $........ Rct. #........) $................. Plumbing: .....................--........................................-......-........ .. _............ City Business License #_..._............ Phone:-......_ Strong Motion Fee ..... ...............$........•.50....-... Heating and Cooling _........ ......._.. ............. ..._... . _...._.. Plumbing Permit Fee ............ . ... . ............................ # ..............._._... City Business License #....._......-...-.... Phone:e:...........:........ Electrical Permit Fee ..........--....--....-.........................$.-.................... Architect/Designer: ......-................-....................... Phone:.................... Mach. Htg./Coolg. Permit $............................. $.......-----.._----_. Residential Construction Tax ._..._...............................$..........._.....__. Engineer: ..... ..._........ ...................._..............._......... Phone:.................... own......_............... ._. . .......................... E] Unknown Misc. Fee .............. ......................$..... ... ....... Lender: cerin that in the ...__.of permit Is 6•C50 performance of the work for which This Misc. Fee ..................... ................. $..._......._......... Issued I shall not employ any person in any manner so as 10 become subject $ 34.50 to the workman's compensation laws of California." SIGNATURE OF • • APPLICANT/OWNER ........................................................................ DATE........................ Environmental Status: Exempt............ Other..................._....._.......---- '[ cerlily that as the applicant I am licensed undo the provisions of the Design Review Approval: Bldg. ............ Site ............ Sign ............ Contractors License Law and further that my Ulcers, No. ................--........ Use Zone ............ P.D. Conditions ...—.......... .._.. .. .......... _. ..__... in Classification .�Z/,/-�• e. ........ is in full force and effect: or ... Gond. Use Permit # Sp...._...... Variance #............ Parking Spaces..... I aufity that I am exempt from the "Licensed Required" provisions of the Approved By. Date Contractors License Law. (State basis of exemption.) """'-'—"""""""'--"-"'—'--"""""' I hereby acknowledge that I have read this application and state that the above is _ IITr -orrect and agree to comply with all City Ordinances and State Laws regulating • • building. I (We) agree to save, indemnify and keep harmless the City of Cupertino roachment Permit............. Grant of Easement....................... against liabilities, judgments, is and expenses which may in any way rb, Gutter, Sidewalk, Driveway: Replace.......... Repair.......... acture against said City in "Tsuence of the g anon of this per iL' Sewer............ Conn. Fee $........-...... Water................ Meter $.............— SIGNATURE OF_ ;X ( i Agreement for Completion of Public Works Improvements ... ............. APPLICANT/CONTRACTOR ...... . .... DATE .... 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 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 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. ............. 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 -1- . ... 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)...................................................... Vacuum Breakers ....._.............._. ............ .. ............3,50.. ............ New Residential Occupancies Flat Rate Interceptor........ Water Softener........ .............................4.00. ..........- Plumbing Piping without fixtures ...................................4.00-.............. 0-500 sq, it. $22.00 1501-1750 $34.50.............................. Misc. (See Ord. Current) .................................................... 501-750 24.50 1751-20000 37.50.............................. ...$ 751-1000 26.00 2001-2250 39.50.............................. Permit Fee .............................(plu..........ally......................$ 6.00 1001-1250 28.50 2251-2500 42.00.............................. TOTAL PLUMBING PERMIT FEE (plus penalty if app. E 1251-1500 32.00 2501-2750 49.50.............................. APPLICATION FOR HEATING/COOLING PERMIT Permit Fee...............................................$6.00 TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.p) $ PERMIT INSTALLATION NO. EACH FEE Forced Air Unit........ _.to 100M ---............... .........$ 6.Oo... ............ • • ' ' over 100M ........................ . 10.00.. ........... Comfort Cooling Unit.....to 3 ton/HP _._...................... 6.00... ........... Forms / Foundation .............................. By:........ . ..... . Date:....,_......_. to 15 tori......_......... ........ 9.50.............. Plumbing Ground Work ............_.___ ................ ...._....._......._.._. to 30 ton/HP........................... 12.00. _.......... Rough Electrical ........ ....... ......................_._ to 50 ton/HP...........................17.00.............. arae - Plumbing and Heating ..........i Space Heater........ Wall Heater ..._. ........... ............ 6.00..- lotion & Energy_.._.._.. ...........)..._.................... ........ ......._... .. ........... _......... Flues - other than above _...._........... .........._..�.. 3.00.. ............ as Test ..............................__..__... . ....................-...... ..........._. -......... Vent Fan: Kitchen........ Bath ...._..._.._................ ........ .. 3.00............... Temporary Power Gas / Elect. ........ ......................... ...........--............ Commercial Range Hood .......... 6.00,,,,,,_........ Electr Final - Building ......_...._._......................_..._....._......... ........... ._............ Misc. (See Ord. Current... ..................................... .................................... Final - Building / Mechaniral ....................... ................ ........................... Permit Fee ._... ..........._--.._.................. ...._................. $ 6.00 Final - Design Review / Landscaping . .... ............................__...____ TOTAL Ht9 / Coo19 Permit Fee (Plus penalty if app. C)) E Final- Public Works ..........................................•...•.•.....••.•. shiret 2 CITY OF CUPERTINO BUILDING PER14IT �hJ Permit No: Address: Date: �- BUILDING PROJECT IDENTIFICATION NVORKERS'COMPENSATION DECLARATION Applicant's )tailing Address I hereby affirm that I have a certificate of consent to self-insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof (Ser7�.,y, Address of Building Policy No.. 7 ny I is S 1 n /)/ Certified copy is hereby furnished. Owner's name Certified copy is filed with the couray building inspection Telephone ;:o. epartm n or countlicanty department. ate ,gpp Contractor's Name '!, 8 � \�Oo I�� D Contractor's wiling Address CERTIFICATE OF EXEMPTION FROM WORKERS' 9S/ a COMPENSATION INSURANCE Lic. No. a (This section need not be completed if the permit is for one 'Architect or Engineer _ hundred dollars 0100) 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 many manner so as to become subject to the R'orkers' 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 under proxisions 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 men a in full force and effectcomply with such provisions or this permit shall be deemed revoked. License Class Lic. Number Date Contractor CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is aconstruction lending agency for the performance of the work for which this permit is issued (Sec.3097, O\VNER-BUILDER DECLARATION Civ.C.).Lender's Name I hereby affirm that 1 am exempt from the Contractor's License Lender's Address - ,® Law for the following reason (Sec.7031.5, Business and Professions Code: Any city or county which requires a permit to construct,alter, 1 eerB(y that 1 have read this application and state that the above improve,demolish,or repair any structure,prior to its issuance,also information is correct. I agree to comply with all city and countyordinances 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 Law(Chapter 9(commencing with Section 7000)of Division 3 of the p p y P purposes. Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 Signature of Applicant or Agent Date by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500).): - 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 "Plca 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 in processingand issuing your building permir.Nobuildiug permit owner-builder will have the burden of proving that he did not build will be issued until this verification fs received. or improve for the purpose of sale.). 1. I personally plan to provide the major labor and materials for 0 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 Lav does not apply to 2 I (have/have not) signzd 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 & I have contracted with the following person(firm) to provide the Contractor's License Law.). the proposed construction: ❑ 1 am exempt under Sec. , B.&P.C. for this Name reason Address City Date Owner Phone Contractors License No. 4. 1 plan to provide portions of the work, but I 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 I have contracted(hired) the following persons to provide the work indicated: Name Address Phone Type of Work Signed: Property owner Social Security number Date. ���� . 1���'� u ��� I I