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1252 (2) CITY OF CUPERTINO APPLICATION FOR RESIDENTIAL BUILDING PERMIT PERMIT NUMBER • AN; FOR-APPLICANT TO FILL IN CERTIFICATE 0 OCCUPANCY BUILDING INSPECTION DIVISION 7FET ADDXrS OF FIR EC'L�, ..................................... ......... DEPARTMENT USE ONLY Legal Description: Tract....... .............. Block.........:.. Lot...................... Plans Received By....................................................Date ..------ ..... Description of Work: ....06 LEF-CIT" ............. REO.: Plans.... Survey.... Cates: Struc..... Energy.... Elect..... Mach.... 1st S tr.u 1 c.It Improvement. .1.. . . . I .1. ..0.In-Parcel:. .. Y.e a. No-.Area of Bldg... Plans Checked By................ Date Separate Structure................ or Addition/Alteration to Exist. Bid Application Approved By...........4-4Stories..._......._.. 9..... . . .. -.-......... Date ...ell! No. of Use of Building ... .... ... ................. Validated By........._.....__........_. .................... Date Valuation of Project: $..._-.- Compensation Certificate Verified By --.... ...-... Date .................... Owner: Pho*ne:,."*.- 0WWW.TU@7r9TX-T;T*Tr7X= $ CITY C. CU.-z.".Tfl41O Contractor 'c City Bus. Lic. # Contractor's Address: 1� Phon Permit Fee (plus penalty it applicable) ... Contractor - Electrical: Lh),0�5-. �C �C Plan Check Fee (less deposit of$.......... Rct. #Ati C4 $ T) City Business License In ..I...- $.......-.._..._.... P one�Q.S.J.�.O Energy Plan Check Fee (Dep. of $....._. Ret. #........) .................. Plumbing: .._......... ............. ......... ................__._.......... Strong Motion Fee ................ C4 Business License #_.-......._..... Phone:.....-........... .... ...---........... Heating and Cooling ......... ........... ... Plumbing Permit Fee ........................-...... ....-I /$..._... Electrical Permit Fee ...--......... ....... ........... ........ City Business License .......... Phone:.................... Mach. Htg./Coolg. Permit $............................. $........._.......... Architect/Designer: ............... ..... ...--....... ..... Phone:-................ Residential Construction Tax ...... ............ ........$................._.... Engineer: . . ........... ................. ................- Phone:................. . Misc. Fee ................................ .................... $ Lender: - � .... ...... .. .. .... .........__........... .. ..... - C) Unknown Misc. Fee .......................----.............. ........... ................ "I certify that in the Performance of the walk for which this permit is issued I shall not employ any person in any manner so a,to become subject $ to the workni P' .Pomp asationt onlito Ia.,, SIGNATURE OF ZONING REQUIREMENTS APPLICANT/OWI .... . DATE.P/pilil Environmental Status: Exempt . ..... Other ... ....----......... 'I certify that as the applicant I am licensed ad, the Provisions of-the . Design Review Approval: Bldg. ........ . Site ............ Sign ............ Contractors License Law and further that my Lici No. ........... Use Zone ........... P.D. Conditions .... .......-............. ...........-......... in Chicrification .. .............. - ............ is in full force and effect c*r Cond. Use Permit #............ Variance ....... Parking Spaces............ I.certify that l am exempt from the "Licensed Required" provision, of the Approved By.............--........... ....................... Date ............ .............. Contractors License Law. (Slate 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 building, achment Permit.... ........ Grant of Easement........................ I two) agree to save, indemnify and keep harmless the city of Cupertino o against liabilities, judgments, costs and expenses which may in any way ®rbGutter, 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 ...... APPLICANT/CONTRACTOR ...... ......... .......--.... DATE .................. Plans Checked By........ Date........ Approved By........ Date...._....._....... NOTE: when properly validated this form constitutes a Building Permit. This permit aidruirss and becomes null and void should work not be commenced within 120 days from validation date, or should authorized construction be suspended of abandoned for a period of 120 days after work is commenced. PERMIT INSTALLATION NO. EACH FEE -Mondi Light Outlets...../.. Switches / I APPLICATION FOR PLUMBING PERMIT Fixtures............ Receptacles....... PERMIT INSTALLATION NO. EACH FEE TOTAL NUMBER (less than 1000 watts) $ .50 3.. Gas System with up to 5 outlets .,...............................-$400. ............. Range........ Cooking Unit....._.. Oven.... ....... ............... 2.00 Each additional outlet ........-................................ 1.()0 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.................... ........... Misc. (see Ord. current .... Vacuum Breakers ........................ _ Y- --�Yt-g�L,--e............................... ...... .............3.50.............. Now Residential Occupancies Interceptor........... Water Softener........ .......... ...-..........4.00. ............ 0-500 sq. ft. $22.00 1501-1750 $34.50.............................. Plumbing Piping without fixtures ..................._I............4.00.1"' , I'll 501-750 24.50 1751-20000 37.50........................... Misc. (See Ord. Current) .................................................... 751-1000 26.00 2001-225C 39.50.............................. Permit Fee ...... -.................................._.........................$6.00 1001-1250 28.50 2251-2500 42.00...........................*­ TOTAL PLUMBING PERMIT FEE (plus penalty it app. C]) $ 1251-1500 32.00 2501-2750 49.50.............................. APPLICATION FOR HEATING/COOLING PERMIT PermitFee...............................................$6.00 TOTAL ELECTRICAL PERMIT FEE (Plus penalty if app.Cl) $//, PERMIT INSTALLATION NO. EACH FEE INSPECTION RECORD Forced Air Unit..................to 100M ............. ........ �-$ 6.00 ------ over 100M ................. __ . 10.00 .-... -- 10.00 ........... Forms / Foundation ... ........... ............ . BY:_...... . ..... . Date:....._......._ Comfort Cooling Unit......to 3 ton/HP ...... ........ 6.00................ to 15 ton/HP.. ...... 9.50.............. Plumbing Ground Work ...... . ....... ..... 30 ton/HP 2�00 * Rough Electrical .....-................ .... ... . ..-. ............. to ........ .. ...... I . ............ a - Plumbing and Hosing to 50 ton/HP................ ...... 77.00.. ........... .. ........... I g a t Space Heater........ Wall Heater ................-...... 6.00 8,"E err IT - Pum Ia'I on 0 gy ....... ......... Flues - other than above .................................. Test .. .. ....... 3.00- ............ Vent Fan: Kitchen....... Bath ............ ................ --J.. 3.00............... p or S r -P Ga Eta ...... 'in a y Commercial Range Hood ....... ......-........ ..... 6.00............... Fine _ ElectricalI .... ...... ...... ............ Misc. (See Ord. Current.... ............ ....................]. .....i....... . Final - Building/ Mechanical ........ ........... . .. ................... Permit Fee ........... ...... '6**.00 ' Final - Design Review / Landscaping ................._ Final-Public Works ........................................................... TOTAL Htg./ COO19. Permit Fee (plus penalty if app. C]) S Sheet 2 CITY OF CUPERTINO BUILDING PErVIT Permit No: A, J Z Address: 12 2 Date: r BUILDING PROJECT IDENTIFICATION WORKERS'COMPENSATION DECLARATION Applicant's Mailing address I hereby affirm that 1 have a certificate aI consent to sal(-insure, Z"�i�F" T,•^ o or a certificate of Workers'Compensation Insurance,or a certiAed �-+ f (Sec sP b.C.i. yI A Address of Building copy thereo // 7 7 C l r"`S��f Cr Policy No.a 7 G um any Telephone No. Owner's name Mr. tArrm f, ❑ Certified copy is hereby furnished. ❑ Certified copy is filed with the countx building in department or counts.-0 ^/31 q P r�m (pl if--- ��� Contractor's c[or's Name �t �sT`+t'S ��tcT^%C Applicant co, y-„/ � � Alrrv. Contractor's Mailing Address ��.e - e •+ u. CERTIFICATE OF EXEMPTION FROM WORKERS- Lic. No. 8. COMPENSATION INSURANCE (This section need not be completed if the permit is for one 'Architect or Engineer hundred dollars (5100) or less.) Architect's or Engineer's Address Lia No. I certify that in the performance of the work for which this permit is issued,I shall not employ any person in an% manner so as to become subject to the Workers'Compensation Laws of California. LICENSED CONTRACTORS DECLARATION Date Applicant I herebyaffirm that [am licensed under provisions of Chapter 9 NOTICE TO APPLICANT: If, alter making this Certificate of • P s 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,app my license is in full force and effect. comply with such provisions or this permit shall be deemed revoked. License Class `" Lic. Number 37%q0 [�j Date y�/.��Go Contractor G7171.,,trJ r-/ecF,C. CONSTRUCTION LENDING AGENCY J, 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 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 cerci f.'that I have read this application and state that the above improve,demolish,or repair any structure,prior to its issuance,also information is correct. 1 agree to comply with all city and count requires the applicant for such permit to file a signed statement that ordinances and state laws relating to building construction, and he is licensed pursuant to the provisions of the Contractor's License hereby authorize representatives of this county to enter upon the Law(Chapter9(commencing with Section 7000)of Dix isicLic the above-mentioned property for inspection purposes. Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 70315 Signature of App&ant or Agent p,1e 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 improvements are not ini ended 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 issuingyour building permit Nobuildiug permit owner-builder swill 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.). I. I personally plan to provide the major labor and materials for ❑ 1,as owner of the properly,am exclusively contracting with eotruetion of the proposed property improvement (yes or no) licensm ed contractors to construct the project (Sec.7044,Business and Professions Code: The Contractor's License Law does not apply to 'L 1 (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.&P.C. for this Name reason Address City Datc. Owner Phone Contractors License No. 4. 1 plan to provide portions of the work, but I have hired the following person to coordindte,supervise, and provide the major work- Name Address City Phone Contractors License No. S. 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 l� Signed: Property owner Social Security number Date.