1635�i
c -Y
PERMIT NUMBER 3sFOR —
'APPLICANT TO FILL IN
9111,
Encroachment Permit ........................ Grant of Easement.....................
V� Curb, Gutter, Sidewalk,, Driveway: Replace Repair
\Sewer ............ Conn. Fee $...... ........ . Water... ............. Meter $ ................
•� Agreement for Completion of Public Works Improvements ..................
•pF Plans Checked By........ Date........ Approved By........ Date ....................
PERMIT INSTALLATION
Light outlets../%. Switches..........
Fixtures............ Receptacles..j.... ....
TOTAL,NUMBER (less than 1000 watts)..
Range........ Cooking �1nit........ Oven.........
Dryer.... Garb. Disp.1.. Dishwasher.........
SERVICE OR TEMPORARY POWER to
100 amp/$5.00, 200/$7.00, 500/$0.00
800/$20.00, 1200/$40.00 ....................
MOTORS, Generators, Welders, Heaters,
per HP—KW—KVA to 1/$2.00, 5/$3.50
20/$8.50, 60/$10.00, 100/$12.00,
500/$15.00 ..............................................
Signs with I XFMR......................................
Each additional XFMR/Time Clock .,
Annual Electrical Maintenance
Other (see Ordinance Current) .................
NO. 1 EACH I FEE
STREET ADDRESS OF PROJECT:
.................................. Lot.....'......... .
Legal Description: Tract'
v................).... Block
Description of Work:.L1eM.'la............ --- ..........._......._........... ....
let Struct. Improvement on Parcel: Yes.... No.... Area of Bldg.......'
Separate Structure ............ or Addition/Alteration to Exist. Bldg.
No. of Stories......._....... Us of Bgllding ............
Valuation�j Pro�1'ect:yfic
... O..0........_................._.......
................................ .
Owner:... ...9.ce" .................................... Phoney. G^
Contractor: e.S..&W...... CityBus. I.C. e................................
Address: /. .�Y....A4adizL••o-F.-e+.S......... Phone:.Y..`V/71.3.7.2
Contractor - Electrical:..e..Y....../.P`K.K............................................
City Business License +r .................... Phone1.Y.4:.3.,r
Plumbing: ................ ___ .................... ...................................
City Business License +r .. ... ........ Phone:...........
Heating and Cooling /��$...%CN� ............................. .....
City Business License �.................... Phone:61/ -?T?�.
Architect/Designer:.................................................. Phone:....................`
Engineer:..........-........................................................ Phone:..................
Unknown
Lender:....................................................................................Q. .... ---
............ "I certify that in the performance of the work for which this permit I
issued I shall not employ any person In any manner so ea to become subject
to the workman's cgmpensation laws of California."
SIGNATURE OF��`
APPLICANT/OWNER it/,gyp"/'/�[,-`%'..Cl.'C(... DATE
..... certify that as the applicant I am licensed under the previsions of the
Contractors License Law and further that my License No. 2$.'1.g.G......
In Classification ........................................ Is in full force and effect: or
........... 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 slate that the above Is
correct and agree to comply with all City Ordinances and Slate Laws regulating
building.
I (We) agree to save, indemnity and keep harmless the City of Cupertino
against liabilities, judgments, costs and expenses which may In any way
acture against said City In consequence of the granting of this permit.
SIGNATURE OF A , y� ! ".ATE
/�� 9
APPLICANT/CONTRACTOR ..... /C �+-Oq7•'•. DATE ........_.vL...S ��.`..'
NOTE: When properly validated this form constitutes a Building Permit. This
permit expires and becomes null and void should coed, not be commenced within
120 days from validation tlmo, or should authorized construction be suspended or
abandoned for a period of 120 days after work Is commenced.
Q
Plans Received B ........................ ...............
up
Date ..............a.'.....
REO.: Plans.... Survey.... Calcs• Struc..... Energy.... Elect..... Mach.:...
Plans Checked By....................i%...L-../........... ._.....
Date .......
Application Approved By .....__ ...L.......__........
Date ......^........
.....
Validated BY ................................................... .. ...
Compensation Certificate Verified By ........ .......
......
Date ...
Date ._�� Y_,f�
Permit Fee (plus penalty if applicable) ...�.........-�
........
$.. . 0��ii.....d.,p:..
Plan Check Fee (less deposit of $.......... Rct. #..........)
$.. ..y.!......`-'
energy Plan Check Fee (Dap. of $........ Rct. #........)
Strong Motion Fee
$...............
$_........t.. ..
.............. ...--- .................... ..........
.... ...
Plumbing Permit Fee ................................................
$...
$...:��.......}�...
lectrical Permit Fee ......................................................
..
I Mach. Htg./Coolg. Permit $ ..............................
$... �.. ..l.4_V..
ConstructionTax.............................................$.......................
Vacuum Breakers ............................................ .......... ... 4.50 ........
,Sewer Conn. Fee .............. Water Conn. Fee ..............
$ ................
Landscape Fee .................... Street Tree Fee ............
$._................... -
Misc. Fee........................................................................
$..............iz
Type' Const......... Group........ Div.... .. Occ. Load........ No. Exits........
Floor Loads: 1st.... 2nd.... Other.... Sprinklered....
Area Sep. Walls....
.50 ..
lAv Environmental Status: Exempt ............ Other ........................................
Design Review Approval: Bldg ............. Site ............
t
Sign ............
Use Zone ............ P.D. Conditions............................................................
Permit Fee........................................................................$ 6.00
(f4, Cond. Use Permit a...... Variance ♦...... Parking Spaces.... Load. Sp.....
,�0 Approved By ........................................................... Date ..............................
Encroachment Permit ........................ Grant of Easement.....................
V� Curb, Gutter, Sidewalk,, Driveway: Replace Repair
\Sewer ............ Conn. Fee $...... ........ . Water... ............. Meter $ ................
•� Agreement for Completion of Public Works Improvements ..................
•pF Plans Checked By........ Date........ Approved By........ Date ....................
PERMIT INSTALLATION
Light outlets../%. Switches..........
Fixtures............ Receptacles..j.... ....
TOTAL,NUMBER (less than 1000 watts)..
Range........ Cooking �1nit........ Oven.........
Dryer.... Garb. Disp.1.. Dishwasher.........
SERVICE OR TEMPORARY POWER to
100 amp/$5.00, 200/$7.00, 500/$0.00
800/$20.00, 1200/$40.00 ....................
MOTORS, Generators, Welders, Heaters,
per HP—KW—KVA to 1/$2.00, 5/$3.50
20/$8.50, 60/$10.00, 100/$12.00,
500/$15.00 ..............................................
Signs with I XFMR......................................
Each additional XFMR/Time Clock .,
Annual Electrical Maintenance
Other (see Ordinance Current) .................
NO. 1 EACH I FEE
STREET ADDRESS OF PROJECT:
.................................. Lot.....'......... .
Legal Description: Tract'
v................).... Block
Description of Work:.L1eM.'la............ --- ..........._......._........... ....
let Struct. Improvement on Parcel: Yes.... No.... Area of Bldg.......'
Separate Structure ............ or Addition/Alteration to Exist. Bldg.
No. of Stories......._....... Us of Bgllding ............
Valuation�j Pro�1'ect:yfic
... O..0........_................._.......
................................ .
Owner:... ...9.ce" .................................... Phoney. G^
Contractor: e.S..&W...... CityBus. I.C. e................................
Address: /. .�Y....A4adizL••o-F.-e+.S......... Phone:.Y..`V/71.3.7.2
Contractor - Electrical:..e..Y....../.P`K.K............................................
City Business License +r .................... Phone1.Y.4:.3.,r
Plumbing: ................ ___ .................... ...................................
City Business License +r .. ... ........ Phone:...........
Heating and Cooling /��$...%CN� ............................. .....
City Business License �.................... Phone:61/ -?T?�.
Architect/Designer:.................................................. Phone:....................`
Engineer:..........-........................................................ Phone:..................
Unknown
Lender:....................................................................................Q. .... ---
............ "I certify that in the performance of the work for which this permit I
issued I shall not employ any person In any manner so ea to become subject
to the workman's cgmpensation laws of California."
SIGNATURE OF��`
APPLICANT/OWNER it/,gyp"/'/�[,-`%'..Cl.'C(... DATE
..... certify that as the applicant I am licensed under the previsions of the
Contractors License Law and further that my License No. 2$.'1.g.G......
In Classification ........................................ Is in full force and effect: or
........... 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 slate that the above Is
correct and agree to comply with all City Ordinances and Slate Laws regulating
building.
I (We) agree to save, indemnity and keep harmless the City of Cupertino
against liabilities, judgments, costs and expenses which may In any way
acture against said City In consequence of the granting of this permit.
SIGNATURE OF A , y� ! ".ATE
/�� 9
APPLICANT/CONTRACTOR ..... /C �+-Oq7•'•. DATE ........_.vL...S ��.`..'
NOTE: When properly validated this form constitutes a Building Permit. This
permit expires and becomes null and void should coed, not be commenced within
120 days from validation tlmo, or should authorized construction be suspended or
abandoned for a period of 120 days after work Is commenced.
PermitFee........................................................................ $ 6.00 '
TOTAL ELECTRICAL PERMIT FEE (plus penalty if app. p)
Forms / Foundation .............................
.Plumbing Ground Work ......................
itougn
,' me ctrl' @•a
n eafin
nerI�u:. iotn / Energ
......... :
........ .C.�.� ................
Temporary Power Gas / Elect..........
Final - Electrical .................... - ...... ......
Final - Building / Mechanical .............
Final - Design Review / Landscaping
By: ................... 4 Date:................
Final — Public Works............ ........................ ..
FohynR4
Y
Q
Gas Sytem with up to 5 outlets ................................... $ 4.00 ........
$ .50
Ix A)
Each additional outlet ............................................ 1.00 ........
2.00 .
..... .,.499 1
Water System (Installation, Alt. or Repair) ................ 4.00 ........
2.00 ......,08
to 15 ton/HP ........................... P.5o ...............
Water Closet.... Water Heater.... Ld. Tray .................... 4.00.........
2.00 .
.............. A
Lavatory.... Shower Pan.... Bathtub.... Sink.................. 3.00.........
I.
Wash. Mach..... Dishwasher.... Garb. Disp..... .... ......... : 3.00.........
............................
Vent Fan: Kitchen........ Bath ........................... ............ 3.00 ...............
Commercial Range H....
Sewer.............................................................................. 8.00, ........
`
Lawn Sprinkler Sys. $6.00 Ea. add Sys. $2.00 ......... .............. ........
6.
Vacuum Breakers ............................................ .......... ... 4.50 ........
TOTALrHtg./ Coolg.Permit Fee (plus penalty if app. f]) $ da
Slop Sink........ Floor Sink........ Floor Drain 4,00 ........
................
......00 ...
..............qUrinal....
Interceptor.... Water Softener.......................... 4.00 ........
2.00.
Plumbing Piping without fixtures .................................. 4.00
.50 ..
Misc...............................:.......................................................................
25.00 ..
.............
Permit Fee........................................................................$ 6.00
..............
TOTAL PLUMBING PERMIT FEE (plus penalty it app. p) S
PermitFee........................................................................ $ 6.00 '
TOTAL ELECTRICAL PERMIT FEE (plus penalty if app. p)
Forms / Foundation .............................
.Plumbing Ground Work ......................
itougn
,' me ctrl' @•a
n eafin
nerI�u:. iotn / Energ
......... :
........ .C.�.� ................
Temporary Power Gas / Elect..........
Final - Electrical .................... - ...... ......
Final - Building / Mechanical .............
Final - Design Review / Landscaping
By: ................... 4 Date:................
Final — Public Works............ ........................ ..
FohynR4
Y
APPLICATION s• HEATING/COOLING PERMIT
PERMIT INSTALLATION NO, EACH FEE
' to
O
Forced Air Unit ............... to 100M .............................. $ 6.00 ...............
t^
over 100M ............................. 10.00 ...............
Comfort Cooling Unit..... to 3 ton/HP .......................... 6.00 ...............
to 15 ton/HP ........................... P.5o ...............
to 30 ton/ HP .........................'.12.00...............
to 50 ton/ HP .......................... 17.00 ...............
Space Healer........ Wall Heater ...................................... 6.00 ..............•
Flues -' other than above...............................................1 3.00 ...............
(�
W
Vent Fan: Kitchen........ Bath ........................... ............ 3.00 ...............
Commercial Range H....
Misc ......................�sCT...../..u.....7..............................................
6.
2 N
TOTALrHtg./ Coolg.Permit Fee (plus penalty if app. f]) $ da
I I r ljvw `
W: -r-