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167811.1 , I DEPARTMENT USE ONLY Plans Received By .................................................... Date ......................... REO.: Plans.... Survey.... Calcs: Struc..... Energy.... Elect..... Mach..... Plans Checked By .................................................... Date ._ ..................... Application Approved By ......................................... Date ......................... ValidatedBy............................................................. Date ......................... Compensation Certificate Verified By .................... Date ......................... U . •-e $ 8.00 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 ................................................ $...10....().61.... ElectricalPermit Fee ...................................................... $....................... Mach. Htg./Coolg. Permit $ .............................. $-.................... .. Construction Tax.............................................$....................... Sewer Conn. Fee .............: Water Conn. Fee .............. $....................... Landscape Fee .................... Street Tree Fee ............ $....................... Misc. Fee........................................................................ $ ....................... Type Const......... Group........ Div......... Occ. Load........ No. Exits........ Floor Loads: tat.... 2nd.... Other.... Sprinklered.... Area Sep. Walls.... ZONING Environmental Status: Exempt............ Other ........................................ Design Review Approval: Bldg ............. Site ............ Sign ............ Use Zone ............ P.D. Conditions............................................................ Cond. Use Permit #...... Variance #...... Parking Spaces.... Load. Sp..... ApprovedBy ........ :............................. ..................... Date ........................... roachment Permit ........................ Grant of Easement........................ urb, 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. EACH FEE Light Outlets............ Switches............ 1.00 Fixtures............ Receptacles............ 4.00 TOTALNUMBER(lessthan 1000watts).....................$ .50 .. .......... Range........ Cooking Unit........ Oven ........... .............. .._ 2.00 ........... . 3.00 Dryer.... Garb. Disp..... Dishwasher .... ........ ............. .... 2.00 ........... 3.00 SERVICE OR TEMPORARY POWER to............. .... 2.00 ........... 8.00 100 amp/$5.00, 200/$7.00.-500/$9.00 3.00 ........... 800/$20.00, 1200/$40.00............................................................ 4.50 MOTORS, Generators, Welders, Heaters, 4.00 per HP-KW-KVA to 1/$2,00, 5/$3.50, 4.00 20/$8.50, 50/$10.00, 100/512.00, 4.00 500/$15.00...................................................................................... I................25.00 Signs with I XFMR................................... ................ ... 2.00 .. ......... Each additional XFMR/Time Clock .................. .50 .......... Annual Electrical Maintenance ............ Other (see Ordinance Current) PermitFee........................................................................ $ 8.00 TOTAL ELECTRICAL PERMIT FEE (plus penalty if app. p) $ Forma / Foundation ............................. Plumbing Ground Work ....................... ugh Electrical ................................... me - Plumbing and Heating ......... L lation / Energy ............................. Test............................................... Temporary Power Gas / Elect.......... Final - Electrical ................................... Final - Building / Mechanical ............. Final - Design Review / Landscaping Final - Public Works ................... CUFEAi1Nu PERMIT NUMBERJ 16 7 STREET ADDRESS OF PROJECT: ................... ...._............... ....... Legal Description: Tract ........................ Block............ Lot............. Description of Work: ..... rzL1r7Sr.. G[A..-.,,p......................................... tat Struct. Improvement on Parcel: Yes.x No.... Area of Bldg ............... Separate Structure............ or Addition/Alteration to Exist. Bldg........... No. of Stories...... 3..... Use of Building ... CFF..1 .�:F............................ Valuation of Project: f.GO(-5 ................................................. Owner: ..YiY.1.Y..... .r.F1oiv*AT)9.1H....... -1M.tT.9W... Phone: .................... Contractor:7XIL._ 0.4154ScH- City Bus. Lia .............................. . Address: .1520...1.v.14.ITR...... D.. Ph one: 37.1.'.5331.4 ti;h-l' ...0._ Contractor - Elecincal:.... 55aWV1�.I c�F�%Z...................................... City Business License #.................... Phone:.................... Plumbing: .............................................. ....................................... City Business License #.................... Phone:.................... Heating and Cooling .......... ............................... :........... ............. City Business License #.................... Phone:.................... Architect/Designer:.................................................. Phone:.................... Engineer: .......................................... __ .................... Phone:................. Unknown Lender: ............... ..................................................................... Q................. ............ "I certify that in the performance of the work for which this permit Is Issued I shall not employ any person in any manner 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 on Contractors License Law and further that my License No. _.... In Classification ......... . ............................. is In full force and affect: or ............ I certify that I am exempt from the "Licensed Reg: 'red" provision of the Contractors License Lew. (State beats 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. J (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costa and expenses which may in any way acture against said City I can a uenca of the granting of this permit. - SIGNATURE OF APPLICANT/CONTRACTOR ......`...... .. -__ DATE..L.Z112�A.0. NOTE: When property validated this form ouesOtuW a SnOding Permit. This permit expires and becomes null and void should work not be Prnrrlenced Wob 120 days ham validation daft, or should authodxad constructionbe suspended or abandoned for a period of 120 drys after work Is eommeneea. , , , Gas Sytem with up to 5 outlets ._ .......................AL....$ 4.00 Each additional outlet ............................................ 1.00 Water System (Installation, Alt. or Repair) ................ 4.00 Water Closet.... Water Heater.... Ld. Tray .......... ......... . 4.00 Lavatory.... Shower Pan.... Bathtub.... Sink ........ ......... . 3.00 Wash. Mach..... Dishwasher.... Garb. Disp................... 3.00 Sewer.............................................................................. 8.00 Lawn Sprinkler Sys. $8.00 Ea, add Sys. $2.00 ...................... 3.00 ........... Vacuum Breakers ............................................ ............. 4.50 Slop Sink........ Floor Sink........ Floor Drain ................ 4.00 Urinal.... Interceptor.... Water Softener .......................... 4.00 Plumbing Piping withouF Iizturea......................�............ 4.00 Misc.............................................................................................. PermitFee..........................................................................f - over 100M ............................ 1G.00 .......... Comfort Cooling Unit ..... to 3 ton/HP ........................... 6.00 .......... Date: ................ to 15 ton/HP ................ ........... 9.50 . ......................... to 30 ton/ HP .......................... 12.00 ........... ......................... to 50 ton/HP .......................... 17.00 .......... ......................... Space Heater........ Wall Heater ...................................... e.00 ........... ......................... Flues - other than above ................................................ 3.00 ........... ......................... Vent Fen: Kitchen........ Bath .............................. ............ 3.00 ........... ......................... Commercial Range Hood .................................. ........... 9.00 ........... ......................... Misc . ....................................................................... ........ ............ .... ..... ......................... Permit Fee........................................................................ S 8.00 ......................... TOTAL Htg./ Coolg. Permit Fee (plus penalty If app. O) S