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2027 - Cpy OF C ryy, A11,44) r PERMIT NUMBER moa 7 A FOR APPLICANT TO FILL IN EET ADDRESS OF PROJECT: tr( 00 T B.. ..a�Er...P2.._....__......._.............................................. Plans Received By....................................................Date .................. Legal Description: Tract.. .................... Bloc ........ Lot...................... G E • ZY1P........./'.!Fort'..................... REO.: Plans.... Survey.... Calcs. Strut..... Energy.... Elect..... Mach..... Description of Work. ..TEa!A/RNZ... Plans Checked By.................. ... .. . Date ..... .. Tat Struct. Improvement on Parcel:Yes.... No.... Area of Bldg............... Application Approved By........ .. Date . Separate Structure............ or Addition/Alteration to Exist. Bldg........... Validated BY......................... ....................Date ............._.. No. of Stories................ Us o,(puildIng .................................................. Compensation Certificate Verified By ...Date _....................... Valuation of I act: $.. .. ✓V.............................................................. • • • • . $ 7/t-o Owner: ....... ff1!A ..k.V. BttT...................... P one• r fJ2 y Contractor: .IeFKP_.��f. EPS C' Bus.Lic. #.. s. .�r0_ �y r ......... Permit Fee (plus penalty if applicable) ........................$.��.-.5,V. Address: .(aY��l_$fYA!..ttN.. .. .&.WAY Phone7. / Y...... Plan Check Fee (less deposit of $__...... Rct. #_.......)$............,r.. Contractor - Electrical; ................................................................ Energy Plan Check Fee (Dep. of $........ Rct. #........)$................. City Business License #.................... Phone:.................... Strong Motion Fee ..........................................................$............,S.-.Q.... Plumbing: ............................._................................................ ...... Plumbing Permit Fee ................................................$....................... City Business License #.................... Phone:.................... ElectricalPermit Fee _....................................................$....................... Heating and Cooling ........................................a......................... Mach. Htg./Coolg. Permit $ ..............................$....................... City Business License #.................... Phone:.................... ConstructionTax.............................................$......__............. Architect/Designer: .................................................. Phone:.................... Sewer Conn. Fee .............. Water Cann. Fee ...._........$....................... Engineer: .................................................................... Phone:................. Landscape Fee .................... Street Tree Fee ............$....................... Unknown Lender: ..........................................................................�.................. .......... Misc. Fee ........................................................................$....................... "I certify that in the performance of the work for which this permit is- • • : $ r�r O a Issued I shall not employ any person in any manner so m to become subject to the workman's compensation Iowa of California." Type Const......... Group........ Div......... Occ. Load........ No. Exits........ SIGNATURE OF Floor Loads: 1st.... 2nd.... Other.... Sprinklered.... Area Sep. Walls.... APPLICANT/OWNER ....................................................................DATE......................... • • ............ I certify that as the applicant I am licensed under the ptpvleJ_opq,q(the Contractore Licene Law and further that my Llcenee No. ....... . .....sense ._ Environmental Status: Exempt............ Other............._........................ in Classcertify that„,....1�.. .. " Is In lull force and effect:or "�`Y. .............._............. ............ certity that I en exempt from the lLicensed Rtion., d" provisions;of are Design Review Approval: Bldg. ............ Site ............ Sign ............ Contractors License Lew. (State bmis of exemption., Use Zone ............ P.D. Conditions ............................................................ I hereby acknowledge that I have read this application and stab that the above Is Cord. Use Permit #......Variance 4...... Parking Spaces....Load. Sp..... correct and agree to comply with all City Ordinances and State Lays regulating Approved BY.......................................................... Date ........................... building. I (We) agree to save, indemnify and keep harmless the City of Cupertino • •• • agairst liabilities, judgments,coats and expenses which may In any way y acture against said City Inc nsequencethe ranting of this permit. � ^� roachment Permit........................ Grant of Easement........................ SIGNATURE OF ,I - , ' rb, Gutter, Sidewalk,.Driveway: Replace Repair APPLICANT/CONTRACTO ..f-(j./.V(LN:....... ...... DATE Sewer............ Conn. Fee $................ Water................ Meter$................ e NOTE: When properly vel debd fhb form dedeebW ■ Building PermN. Thio Agreement for Completion of Public Works Improvements .................. permit expires and becomes null and void should work not be dernrir•riutl VAUM Plans Checked By........ Date........ Approved By........ Date.................... 120 day from validation dab, or should authorized construction be suspeMW or abandoned for s period of 120i after work Is commanded. ' �:+ :!,1 1,e • OR PERMIT INSTALLATION NO. EACH FEE PLUMBING PERMIT Light Outlets............ Switches............ PERMIT INSTALLATION INO. EACH ' '•FEE a"� Fixtures............ Receptacles............ Gas Sytem with up to 5 outlets ........................... .......$4,00 ............: TOTAL NUMBER(less than 1000 watts).... .................$ .50 ...-----..... Each additional outtet ............................................ 1,00 .............. Range........Cooking Unit........Oven........... ................. 2.00 ............... Water System (Installation, Alt. or Repair) ..........i_.. 4.00 ............. Dryer.... Garb. Disp..... Dishwasher.... ......... ............I .... 2.00 ............... Water Closet.... Water Heater.... Ld. Tray.................... 4.00 ............. ............ . SERVICE OR TEMPORARY POWER to ... 2.00 ............... Lavatory.... Shower Pan.... Bathtub.... Sink.................. 3.00 ............. . 100 amp/$5.00, 200/$7.00.500/$9.00 Wash. Mach..... Dishwasher.... Garb. Disp..... .............: 3.00 ............. 800/$20.00, 1200/$40.00 ..................... ............. ............................... Sewer .............................................................................. 8.00. ............. MOTORS,Generators,Welders,Heaters, Lawn Sprinkler Sys. $6.00 Ea, add Sys. $2.00................................... per HP-KW-KVA to 1/$2.00, 5/$3.50, Vacuum Breakers ........................................... ............. 4,50 ------------• 20/$8.50, 50/$10.00, 100/$12.00, Slop Sink........ Floor Sink........ Floor Drain ................4.00 ... 500/$15.00 ............................................................ ............. ................ Urinal.... Interceptor....Water Softener.... ...................... 4.00 ............. Signs with I XFMR ...................................... ................ 2.00 ................ Plumbing Piping without fixtures .....................- ..._4.00. Each additional XFMR/Time Clock .. ................ .50 . .............. Misc. .......................................................................�......... ......-..... Annual Electrical Maintenance .................25,00 ................ Permit Fee ..........................................................................E 8.00 Other see Ordinance Current .............. TOTAL PLUMBING PERMIT FEE (plus penalty if app. p) $ ............................. .............. APPLICATION FOR HEATING/COOLING PERMIT ......................................................................... ............................................. Permit Fee ........................................................................ $ 5.00 PERMIT INSTALLATION NO. EACH "FEE TOTAL ELECTRICAL PERMIT FEE(plus penalty if app.p) $ Forced Air Unit...............to 100M ..............................:. $ 8.00 ............... INSPECTION RECORD over 100M .................... .....:.. 10.00 .............. an Comfort Cooling Unit_...to 3 ton/HP................. .......... 6.00 ..........:.... .Forma / Foundation............................... By:.................. Date:................ to 15 ton/HP................ .......... 9.50 ...:........... tubing Ground Work ......................... ................................................... to 30 ton/HP........................1 .12.00 ...............' Ih Electrical ........................................................................................ to 50 ton/HP........... :............. . 17.00 ............... is - Plumbing and Heating .............................................................. Space Heater........ Wall Heater ......................................6.00 ..............: lation /Energy............................... ................................................... Flues - other than above ................................................3.00 ............... Test ..............................................................................................:..... Vent Fan: Kitchen........ Bath ..........................................3.00 .............:. Temporary Power Gas / Elect............. Commercial Range Hood ,,,---- -,.8.00 ,..___•..,,,,,• Final - Electrical ........................................................................................ Misc. ........................................................................................................... Final - Building/Mechanical ................................................................. Permit Fee ........................................................................$ 6.00 Final - Design Review / Landscaping .................................................... TOTAL Htg./ Coolg. Permit Fee (plus penalty If app. p) $ Final — Public Works...........@�..•� . ....... .. ....... .........