1370 UAKS]WOMFORNINIS
I WIN 1 11 11 I-QRF.F:lcm PERMIT NUMBER /3707
.dmL0_1 J:A��N FOR APPLICANT TO FILL IN
�BUILIDINMNBA=rol,---., 1- - STREET ADDRESS OF PROJECT:
DEPARTMENT USE ONLY 20573-S,tevenS ...Cree k-............. ................. .............
Plans Received By ...... .................. .........Date ....--........ Legal Description: Tract ........ Lot............._......,
......
REO.: Plans.... Survey.... Calcs: Struc..... Energy.... Elect..... Mach..... Description o� Work: .............6 2
Plans Checked By.........-...--...... Date 1st Struct. Improvement on Parcel:Yes..XNo.... Area of Bldg.
Application Approved By...-........4.t-L........ Date Separate Structure_........... or Addition/Alta ation.to Exist. Bldg...........
Validated By......................................... Date ..... -/...... No. of Stories.. 2.......... use of uildinq....VIA.c.e............................
Compensation Certificate Verified By .................Date ... .......... Valuation of Project. $..- 40 QVU,�*b...L.......................................
Ism, itiv.,LIldtol.molm!jolopll.401= $ Owner: Ho 1.10
i�e.,.�a�.Pi. ... .... . . . . ........ Phone:
q�.S , 9 *.......
Contractor on...�1�ity �us.Lic. # 15. 1.
Permit Fee (plus penalty if applicable) .................... $............ Address: . . -......W A -oa s . Yie.......#. 15.1.
Permit 7 2
Plan Check Fee (less deposit of $.......... Rct. #_........)$..........._...._.._ Contractor - Electrical: Hay.e.s'....E.1I
Energy Plan Check Fee (Dep. of $........ Rct. #.- $...._...... - City Business Licens�x'.1 . .5'.-IP�oruf�?.5?'-3 4 0 2
a ............. ....... $._......_.........._ ...........
Strong Motion FePlumbing: ......M...&_14._ .IL in
Plumbing Permit Fee ..._......U^...... `-3.`....._......... City Business License .....2.6.6., J. (ii�oneZT 7 S 0
l� - ........ $............_......_. Heating and Cooling ACC
Electrical Permit Fee -: -.. - -i-, ..1:�.- .. -
Mach. Htg./Coog. Permit $ ...... .........*?:......$...-.... ......-- City l3hone j n.
,eg o e,,. 1.,4S'Q'r&1.... Phone:........k7.......
Sewer Conn. Fee .............. Water Conn. I Engineer:
Construction Tax..............��A....... $...... ...... Architect/De igyr. gr'O.Q.�....ROM 03... ...... Phone:. . .
�45�...... -$...... .....-, - - i
Landscape Fee ........... ........ Street Tree Feet............$...._......_...._... Lender: .... 0 a V.1.fl. L
!I.,.�o If
..�r
Misc. Fee .......-........ ......................._...._2\..............._.$..._................- "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 as to become subject
to the workman's compensation laws of California."
Type Const..... .. Group........ Div.......-. Occ. Load........ No. Exits........ SIGNATURE OF
Floor Loads: 1st.... 2nd.... Other.... Sprinklered.... Area Sep. Walls.... APPLICANT/OWNER .............L........................................-......... DATE ............................
ZONING REQUIREMENTS I certify that as the applicant I am licensed under the W01a
Contract.. License Law and further that VIIVL
Environmental Status: Exempt Other.......... .................... in Classification ...................-...... is In full force and effect: or
Licensed Req. �ed" provisions of the
Design Review Approval: Bldg. ............ Site ......-.... Sign .........- I certify that I am exempt from the "Licensed
Contractors License Law, (State basis of exemption.,
Use Zone ............ P.D. Conditions ................................................ I hereby acknowledge that I have read this application and state that the above [a
Cond. Use Permit x.,..-. Variance # Parking Spaces.... Load. Sp..... correct and agree to comply with all City Ordlnan a and State Laws regulating
Approved By...-..................---......................... Date ...... building.
I (We) agree to save, indemni y and ep It r as the City of Cupertino
against liabilities, judgme , costs nd a p as which may in I
a. u
secure against said City 1 onsequ a granting of this t
"gig"EEncroachment Perot............. Grant of Easement....................... SIGNATURE OF �w
I/t�
Curb, Gutter, Sidewalk,. Driveway: Replace - Repair APPLICANT/CONTRACTOR .. ..................... DATE.... ....... .. ....
Sewer............ Conn. Fee $................ Water................ Meter $................ NOTE: When property validate hi r ormillulas a Building innit. This
j
Agreement for Completion of Public Works Improvements .................. permit expires and becomes n sh III work not be commenced within
Plans Checked By........ Date........ Approved By........ Date.................... 120 days from validation dew, a 5 -rized construction be stralsinded or
abandoned for a period of 120 dayt,after work Is commenced.
APPLICATION FOR ELECTRICAL PERMIT i -
PERMIT INSTALLATION NO. �EACH IFTEmEsse APPLICATIOOR PLUMBING
N FPERMIT
Light Outlets............ Switches............ PERMIT INSTALLATION NO.1
EACH FEE
Fixtures............ Receptacles............ Gas Sytem with up to 5 outlets ...................................
$4.00
TOTAL NUMBER(less than 1000 wafts)-........--... ... $ .50 .. ......... 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. ............. I
SERVICE OR TEMPORARY POWER to ..... 2.00 ..... Lavatory.... Shower Pan Bathtub.... Sink................. 3.00. ..........-
too 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 ................-..............
20/$6.50. 50/$10.00, 100/$12.00, Slop Sink........ Floor Sink........ Floor'6rain .... 1,:',f0O ............
4.00 1.............
-.::::: :
500/$15.00 ......--....... .................... ................... Urinal.... Interceptor.... Water Softens ... 4.00
... .............
Each additional XFMR/Time Clock . .80 ........... .........-........... .........I...........................
Signs with I XFMA ................... ...... ... . 2.00 .. .............. Plumbing Piping without fixtures ...... .......
'SC,
2,
Annual Electrical Maintenance 5.00 .... Permit Fee .........................................................................$ 6.00
Other (see Ordinance Current) ................ --. ...............
TOTAL PLUMBING PERMIT FEE (plus penalty If app. 0) 11/0 qO I
.............. .............................................--- ..... APPLICATION FOR HEATING/COOLING PERMIT
.....-................................ ........................ ...... ....... . ...- ... I I
Permit Fee ........................................................................ $ 6.00 PERMIT INSTALLATION NO. EACH FEE
TOTAL ELECTRICAL PERMIT FEE (plus penalty if app.[]) $ -
Forced Air Unit...............to 100M ........................ ......... $ 6.00 ...............
INSPECTION RECORD over 1 DOM ...................... ........ 10.00 ...............
Comfort Cooling Unit.....to 3 ton/HP................... ....I..... 6.00 ...............
Forms / Foundation..........-................- By:.................. Date:................ to 15 ton/HP........................... 9.50 ..............
"tubing Ground Work ......................... ....... ..........--- --................... to 30 ton/HP........................... 12.00 ...............
,allillillillualt Electrical .......-.......... ................ ................................................... to 50 ton/HP.......--............... 17.00 ...............
4Wams - Plumbing and Heating ............................................................. Sace Heater........ Wall Heater ....................................-18.00 ..............
n,ulation p
Energy............................... ............__........ ........................... Flues - other than above ................................................3.00 ...............
Gas Test .......... ........ ...................................................... Vent Fan; Kitchen........ Bath ....... ........ 6.00*3.0o ..............
Temporary Power Gas Elect.............................................................. Commercial Range Hood .................................. ............ ...............
Final - Electrical ..................................... ................................................... Misc. ..........................................................................................................
Final - Building/ Mechanical .................................................................. Permit Fee ........................................................................ $ 6.00
Final - Design Review / Landscaping I.......................I........................... TOTAL Htg./ Coolg. Permit Fee (plus penalty If app. 0) $
Final - Public Works.......................................................
i
CITY OF CUPERTIN&• oFFi�s
GAS SERVICE NOTICE
.To. .4 j
You ore hereby authorized to connect the GAS service for
fOwner or Tenant 1 r��•. i^ %r>n+ _ zQAt ': ;
At
t New Service
.. / a 1
No. of Meters Reconnect
- }
No. of Add. Meters Move Service '
Move Meter .-7 I
`PLUMBING INSPECTORS% li ,J`t'Ylt:�7";•^.� Oo M a40
n
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1