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1075 PERMIT NUMBER FOR APPLICANT TO FILL IN STREET ADDRESS OF PROJECT: . .............. Plans Received By....................................................Date ......................... Legal Description: Tract........................ Block............ Lot...................... REO.: Plans.... Survey.... CaIcs: Struc..... Energy._.. Elect..... Mach..... Description of Work: ................................... 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................ Use of Building ............................................... Compensation Certificate Verified By.............. Date ......................... Valuation of Project: .........................._...................................... $ Owner: ............ ............. .................................... Phone:.................... Contractor: E. City us.Lia.#............ Permit Fee (plus penalty if applicable) ................. $...................... Address:-2.4 Plan Check Fee (less deposit of Rot. #..._.....)$....................... Contractor - Electrical: .............. .................... ............. ............... Energy Plan Check Fee (Dep. of $........ Rot. #........) $....................... City Business License #.................... Phone:.................... StrongMotion Fee ..........................................................$........ ............. Plumbing: .................................................................................... Plumbing Permit Fee ................................................$... City Business License *.................... Phone:.................... Electrical Permit Fee ............. .................................... ...... Heating and Cooling .................................................. Mach. Htg./Coolg. Permit IS .....I........................$....................... City Business License #............_.... Phone:.................... Construction Tax................ ......f....................$...................... Architect/Designer: .................................................. Phone:.................... Sewer Conn. Fee .............. Water COnnA_ee ..............$....................... Engineer: .......__....................................................... Phone:............ Unknown Landscape Fee .................... Street Tree Fee ............$....................... Lender: ........................._... ...................................................Q... Misc. Fee ......................................................................$....................... "I certify that in the performance of the work for which this permit Is • $ issued I shall not employ any portion In any manner so as to become subject to the workman's compensation laws of California." Type Const......... Group........ Div......... Occ. Load........ No. Exits........ SIGNATURE OF Floor Loads: tat.... 2nd.... Other.... Sprinklered.... Area Sep. Wells.... APPLICANT/OWNER .........___........._.............. .................. DATE ............................ ZONING REQUIREMENTS ........ I certify that as the applicant Irian licensed under the PMVJ loe Y. the h It Contractors Licenfw and further that my U Environmental Status: Exempt............ Other............................... in Class 27.. ... - Is in full force and effect: or Design Review Approval: Bldg. ............ Site ......... Sign ....... I certify that I am exempt from the "Licensed Ran. •ed" previsions of the Use Zone ........... P.D. Conditions .... Contractors License Law, (State basis of exemption., I hereby acknowledge that I have read this application and state that the above Is Cond. Use Permit ... Variance #...... Parking Spaces.... Load. Sp..... correct and agree to comply with all City Ordinances and State Laws regulating Aigroved By p .. ................... Date .......................... building. I (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and which In any way occurs against City i7a egu.nc5�.ml,��hnZ).Bgers...Wtlncg Taty is permit. hment Permit........................ Grant of Easement........................ SIGNATURE OF said L utter, Sidewalk,. Driveway: Replace Repair APPLICANT/CONTRACT ........ L�� DATE NOTE: When p It ;his to shell. Sewer............ Conn. Fee $................ Water................ Meter $................ properly constitutes 8 Building Permit. This an .)I . Agreement for Completion of Public Works Improvements .... permit expires a an null and v2 should work not be commenced eighth ate, or , Plans Checked By...._... Date........ Approved By........ Date.................... 120 days from , me, or should authorized construction be suspended or APPLICATION FOR ELECTRICAL PERMIT abandoned for a period of 120 days after work Is commenced. FOR PLUMBING PERMIT PERMIT INSTALLATION NO. EACH FEE APPLICATION Light Outlets............ Switches......... PERMIT INSTALLATION N Fixtures............ Receptacles............ Gas Sytem with up to 5 outlets .......................... ......... $4.00 ...... TOTAL NUMBER(less than 1000 watts) $ .50 ........I....... Each additional outlet ........................................... 1.00 .............. Range........ Cooking Unit........ Oven........ .. ................. 2.00 ............... Water System (installation. Alt. or Repair) ................ 4.00............... Dryer.... Garb. Disp..... Dishwasher.... ........ ....... .... 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.OQ........ .............. . ......... per HP-KW-KVA to 1/$2.00, 5/$3.50, Vacuum Breakers ............................................ 4: 20/$6.50, 50/$10.00. 100/$12.00, Slop Sink........ Floor Sink........ Floor r .... 4.00. ............. --......... 500/$15.00 ................................... ................. ...... ..... Urinal.... Interceptor.... Water Soften ............ 4.00 Signs with I XFMR ................................._. .......... 2.00 Plumbing Piping without fixtures --- ........... 4.0 ............. Each additional XFMR/Time Clock ................. .50 Misc. .......... ........................................ . .. ......... ............. Annual Electrical Maintenance I ....I........ 26.00 Permit Fee ..........................................................................$ 6.00 Other (see ordinance Current) ............................... .............. TOTAL PLUMBING PERMIT FEE (plus penalty if app. 0) Z2 00 ............_.................­­­­......................... .... APPLICATION FOR HEATINGICOOLING PERMIT ......­...............­­.............................. ............. ...... Permit Fee ............_..........._...................................... .... $ 6.00 PERMIT INSTALLATION NO. EACH FEE TOTAL ELECTRICAL PERMIT FEE (plus penalty if app.ED) $ Forced Air Unit...............to 100M ........................... --- $ 6.00 ............... INSPECTION RECORD over 100M ---r......................... 10.00 ............... Comfort Cooling Unit.....to 3 ton/HP................. ........... 6.00 ............... ,..LDrme / Foundation............................... By:......:........... Date:................ to 15 ton/HP................ ........... 9.50 .. robing Ground Work ........................ .... ................. .......................... to30ton/HP..... .. ........1. 12.00 .............. ,iIIIIIIIII15ugh Electrical ..................................... ........................ .. .......... ................................ .....**,*"*"*....... to 50 ton1HP................ . 17.00 ............... Plumbing and Heating .............................................................. Space Heater........ Wall Heater .......................... ......... ...mo ............... latlon / Energy........................................................ ........................... Flues - other than above ...............................................3.00 ............... "Weat .................................................................................................... Vent Fan: Kitchen........ Bath ..........................................3.00 ............... Temporary Power Gas / Elect............................................................... Commercial Range Hood ..._............................ 6.00 ............... Final - Electrical ................................_.. .................................................. Misc. ....................................................................... .......................... Final - Building/Mechanical ............... ................................................... Permit Fee .......................................................................$ 6.00 Final - Design Review / Landscaping .1........................I........................... TOTAL Htg./ Coolg. Permit Fee (plus penalty If app. 0) $ Final - Public Works...........................................................