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1672Plans Received By .................................................... Date .............. .......... REQ.: Plans.... Survey.... CaIcs: Struc ..... Energy.... Elect..... Mach..... Plans Checked By ...................... - ..... fir.. Date Application Approved By ...'............/1.... _.._... Date Validated By ................................................. Date Date Compensation Certificate Verified By .......//._...... . 17.00 Water Closet..:. Water Heater.... Ld. Tray.................... 4.00 . ......... Permit Fee (plus penalty if applicable) ........................ $....................... Plan Check Fee (less deposit of $ .......... Rct. #..........) $ ....................... Energy Plan Check Fee (Dep. of $........ Rct. #........) $ ....................... StrongMotion Fee .......................................................... ............... Plumbing Permit Fee ................ ......... ....... $ ... . ...... ElectricalPermit Fee .......................... ........ .. -.- $....................... Mach. Htg./Coolg. Permit $ .............................. $....................... Construction Tax ............................................. S .... . ............. Sewer Conn. Fee .............. Water Conn. Fee .............. $....................... Landscape Fee .................... Street Tree Fee ............ $....................... Misc. Fee ........................ . ............................................. $....................... Plumbing Pipingwithout fix res4.00 YT, Type Const......... Group........ Div......... Occ. Load........ No. Exits........ Floor Loads: list.... 2nd.... Other.... Sprinklered .... Area Sep. Walls.... 25.00 .1 .............. ZONING REQUIREMENTS Environmental Status: Exempt............ Other ........................................ Design Review Approval: Bldg ............. Site ............ Sign ............ Use Zone ......... - P.D. Conditions ............................................................ Cond. Use Permit e...... Variance a...... Parking Spaces.... Load. Sp..... ApprovedBy ........................................................... Date ........................... 'O (roachment Permit ........................ Grant of Easement ........................ FUrb, Gutter, Sidewalk, Driveway: Replace Repair Sewer............ Conn. Fee $.......:'....... Water ................ Meter $................ Agreement for Completion of Public Works Improvements .................. Plans Checked By........ Date........ Approved By........ Date .................... PERMIT INSTALLATION NO. Light Outlets............ Switches............ Fixtures............ Receptacles............ TOTAL NUMBER (less than 1000 watts) .............. Range........ Cooking Unit........ Oven ...................... Dryer.... Garb. Disp ..... Dishwasher .... ....... .......... SERVICE OR TEMPORARY POWER to .......... 100 amp/$5.00, 200/$7.00.-500/$9.00 800/$20.00, 1200/$40.00 .................... .......... MOTORS, Generators, Welders, Heaters, per HP-KW-KVA to 1/$2.00, 5/$3.50. 20/se.50, so/sio.00, 100/$12.00, 500/$16.00 ......................................................... Signs with I XFMR ...................................... .......... Each additional XFMR/Tima Clock .. .......... Annual Electrical Maintenance .......... Other (see ordinance Current) ............... .. ......... PERMIT NUMBER 116 7 2 - 10 MrATREET ADDRESS OF PROJECT: \1 ./0 -A),le ............................. � f4,6,f+u.i ....... �t Legal Description: Tract .... ................. BIqck.. .......... Lot...................... Description of Work:)( .... Z�r�en ...... ................................. 1st Struct. improvement on Parcel: Yes.... No.... Area of Bldg ............... Separate Structure............ or Addition/ Alteration to Exist. Bldg........... No. of Stories ............ Use of Building .................................................. Valuation of Project: Owner: ...<`% Phone............................... - ...''-: ....... * ...... * ........ - Contractor:.. City Bifs. Lic # Address:1. .............. Contractor- Electrical: .............. ............................. .................... .......... City Business License # .................... Phone:.................... Plumbing: ............................ - ........................................................ City Business License # .................... Phone:.................... Heatingand Cooling ....................... I ............................................ City Business License a .................... Phone: ................... Architect/Designer: .................................................. Phone:.................... Engineer: .................................................................... Phone:.... Unknown Lender: .......................... : ......................................................... "I certify that In the performance of the work for which this parmill Is issued I shall not employ my pawn In any mariner so a to become subject to the workman's compensation laws of California.'! SIGNATURE OF APPLICANT/OWNER...... ............................................................. DATE .... . ... ............ I certify that as the applicant I am licensed under the provision of the Contractors License Law and further that my Ucansaf No. in Classification ..... . ..... . ......................... in In full to" and effect: or ..........I. I certify that I am exempt from the "Licensed Req,',ad" provisions of the Contractors License Law. (State 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 Lewis regulating building. I (We) agree to save, Indemnity and keep harmless the City of Cupertino against liabilities, judgment oats and expenses which may In any way secure against said City iycorpaquence �ol �gr filing of this permit SIGNATURE OF 4.1 . . .. I - YE APPLICANT/CONTRACTOR ... DATE A NOTE: When property validated this farm coffee A• Bulkniq 2i�111111111 permit expires and becomes null and vah alauW wart not ba camnwaed wIM 120 days from valklifflon daft. or should authorized construction be araPsrtdsd a abandoned for a period at 120 days after work Is caramenced. . EACH FEE PERMIT INSTALLATION NO. EACH FEE Gas Sytem with up to 5 outlets ................................... $4.00 1 ....... $ .50 ................ Each additional outlet ................................. ......... . 1.00 ........ 2.00 ............... to 30 ton/HP ................ Water System (installation. All. or Repair) ...... ......... . 4.00 ......... 2.00 ............... 17.00 Water Closet..:. Water Heater.... Ld. Tray.................... 4.00 . ......... 2.00......... . .............. Lavatory.... Shower Pan.... Bathtub.... Sink......_.......... 3.00 Vent Fen: Kitchen........ Bath .......................................... 3-00 Wash. Mach..... Dishwasher.... Garb. Disp ..... .... ......... . 3.00 ......... ............. ............... Sewer ...................... ............................................. ......... . 8.00 . ......... PermitFee ........................................................................ S Lawn Sprinkler Sys. $6.00 Ea. add Sys. $2.011 ........ ............. ........ Vacuum Breakers ............................................ 4 " �:� Slop Sink........ Floor Sink........ Floor Drain ... 4:130 ............................ Urinal.... Interceptor.... Water Softener.............. ... 4.00 ........ 2.00 - Plumbing Pipingwithout fix res4.00 YT, .80 a . ... Mie C . ............. .......... 25.00 .1 .............. Permit Fee ............................................. i ............................ S 8.00 PermitFee ................................................. ...... ............... $ 6.00 TOTAL ELECTRICAL PERMIT FEE (plus penalty If app. 0) $ Forms / Foundation Plumbing Ground Oough Electrical no - Plumbing and Heating .................. ulation / Energy ........ -- ................... ....... Os Test ............................. ................... ...... 'Temporary Power Gas / Elect . ........... ...... Final - Electrical ............................................ Final - Building / Mechanical ...................... Final - Design Review / Landscaping ........ Final - Public Works .......................... V, Date: ................ TOTAL PLUMBING PERMIT FEE (plus penalty if app. 0) ALA a Forced Air Unit ............... to IOOM - ...................... ......... $6.00 over 100M .................... ......... 10.00 Comfort Cooling Unit..... to 3 ton/ HP ................. ......... .. 6.00 to 15 ton/HP ................ ......... .. 9.50 to 30 ton/HP ................ ........ .12.00 to 50 tori .......................... 17.00 Space Heater........ Wall Heater .......................... ........ ... 6.00 RUSS - other than above .................................... ........ ... 3A0 Vent Fen: Kitchen........ Bath .......................................... 3-00 Commercial Range Hood ................................. ........ ... 6.00 Misc. ....................................................................... ......... I ............ PermitFee ........................................................................ S TOTAL Htg./ Coolg. Permit Fee (plus penalty If app. 0) 111 FEE