1377 C w' O ��
P 1 - 10 0 e0 N ' • A I 'JG y1t NO PERMIT NUMBER / 3771
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CA RT C - 0 U A ' FILL IN
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U DI D N& � 0 DI IB ON STREET ADDRESS OF PROJECT:
DEPARTMENT
............:0'U .3..- ..STF.vF... ......C.Yc.�z l..................
Plans Received By--.............. --------------....Date .............. ... Legal Description: Tract._........ ...__..... Block............ Lot......................
REO.: Plans_.. Survey.... Calcs: Struc.._. Energy.... Elect... Mach._.. Description of Work: ....._$.1'.�IILk'�j�. ._ .._�Q.�!C]............._.............
Plans Checked By...............--......... . ............Date ..... ... ...... .. 1st Struct. Improvement on Parcel: Yes..)(. No.... Area of BIdg.62B.I.
Application Approved By..... ..,..L,.,,,.,,.._. Date __ //_�' ' a Separate StructurA............ or Addition/Alteration to Exist. Bldg...........
Validated By......._.._.........._....._...... ........... Date .......-............... No. of Stories.... A ..... Use of Building ..... ..Q.(-.N...=..............
......
Compensation Certificate Verified By.................... Date --.......---.... Valuation o Pro�ect: $.._.. ........... .C:I-
•. • • . $ Owner: ....]�vv h.......$..Ya.v_..vlg... 011 Phone:...................
Contractor:Mote- .. All,C-410..1LCity u c. #....LS..LL.. .... .
Permit Fee (plus penalty if applicable) ........................$................ ...... "
Address: ....1.3.20......1N1..1 �..... 14.K ..... Ph ne:37..7n
Plan Check Fee (less deposit of $..._..... Rct. #..........)$-------'............... ��
Energy Plan Check Fee (Dep. of $........ Rct. #........)$.....-................ Contractor - Electrical: Lice7ka # ....1.13 P e2- .........7.....4-.
City Rusin as Licer�e #..1.].6 Phone:Z S-aL�.3�1
Strong Motion Fee ...................................._................:...$.._.._.._........... Plumbing: ..1:V1. _I`V1_._..1'.1..i2.1:!d 1
Plumbing Permit Fee .......-,.............. ^"�'$,...�__.. City Busin ss License #�E6 ice.. Phone:.2Yi7A.).q
G...f..`._.�....-7,777
Electrical Permit Fee ..........................-........................$ Heating'and'+1 9 9 ..._... ,C. .....1-1.p.f�r..............7,, -.
Mach. Htg./Coolg, Permit $ .................... . 4}.7?.�$t�........._�..._.-. City Busines Licens +Y.I�1.66�.... PIt ne:.`.�.yy.-G.l
r r_ �'�
7777... ...1?........:...$..............._...... ¢
Construction Tax.......................... Architect/Desi ner: _�Y)f,'..._IIVMYY7l.K.l�... Phone:.'{.3"2:71..134
Sewer Conn. Fee .........._.. Wat r Conn. Fe.e
ryv
Engineer: h.............._..._ Phone'-y�.�-��
Landsca a Fee .................... Street Tree Fee ....................... t✓ / Un nown
7777. Lender: .HSJ1M(2......�/�.7777 1 �..C? -... .....�._...............
p � �'" 7777 �..7777 .�...........
Misc. Fee .......................................................................$ ................... "1 certify that In the performance of the work for which this permit is
• . , . ; $ ,�O 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 .........................................7.....................777.. DATE .v.?..1.........1_!.'a.7
ZONING ......7777.. I certify that as the applicant I am licensed under the provisions of the
Contractors License Law and further that my License No. .....................
Environmental Status: Exempt ............ Other... .......... m Classlllcation ....................................... is in full force and effect: or
7 n ..._._....
Design Review Approval: Bldg, Site Sign ...��....... I certify that I em exempt from the "Licensed Req,'•etl" provisions o/the
"...--."' """"""" "'"""'""" Contractors License Law. (State basis of exemption.,
Use Zone ............ P.D. Conditions ............................................................ I hereby acknowledge that I have read this application and elate 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
IApproved BY........................................................... Date ....-..............7..... building.
I (We) agree to save, Indemnify and keep harmless the City of Cupertino
•• agalrst liabilities judgments costs and expanses which may In any way
acture against said City I Sequa a of the gran 0f this
Encroachment Permit........................ Grant of Easement.._.............-..... SIGNATURE OF 1
Curb, Gutter, Sidewalk,. Driveway: Replace Repair APPLICANT/CONTRACTOR ... ................. ......////..��. ?'BATE ....1.. ..... . .L7.f.r
Sewer............ Conn. Fee $................ Water................ Meter $.....--...... NOTE: When properly validated this fo eoneMetal a Building PemtN. This
Agreement for Completion of Public Works Improvements .................. permit expires and becomes null and Vold should wait not be commend a1Wn
Plans Checked By........ Date........ Approved By........ Date.................... 120 day from validation data, or Mould authorized construction be suspended or
abandoned for a period of 120 days after work Is commenced.
PERMIT INSTALLATION NO. EACH FEE APPLICATION FOR PLUMBING PERMIT
Light Outlets...........- Switches............ PERMIT INSTALLATION NO. EACH I FEE
Fixtures............ Receptacles............ Gas Sytem with up to 5 outlets ....................................$4.00
TOTALNUMBER(less than 1000 watts) ... ............. ... $ .50 Each additional outlet .............7..........---............... 1.00 .............
Range........ Cooking Unit........ Oven.........- .--....... 2.00 ........7777... Water System (Installation, Alt. or Repair) ................ 4.00 .............
Dryer.... Garb. Disp..... Dishwasher.... ........ ................. 2.00 7777....._..... Water Closet.... Water Heater.... Ld. Tray.......... ......-... 4.00..............
SERVICE OR TEMPORARY POWER to ... 2.00 777..........7. Lavatory.... Shower Pan.... Bathtub.... Sink.................. 3.00..............
100 amp/$5.00, 200/$7.00, 500/$9.00 -'1 Wash. Mach..... Dishwasher.... Garb. Disp..... ............. . 3.00 .............
800/$20.00, 1200/$40.00 ..................... . -........�.........a�. 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 ............................................ ............. 4.50..............
20/$6.50, 50/$10.00, 100/$12.00, Slop Sink........ Floor Sink........ Floor Drain 7777............ 4.00..............
500/$15.00 ......................................................................-.. .....-........ Urinal.... Interceptor.... Water Softener.... _.................-.. 4.00 .........._.
Signs with I XFMR .....................7.......-....... ............. ... 2.00 .. .............. Plumbing Piping without fixtures ...................... ............ 4.00 .............
Each additional XFMR/Time Clock .. ................. .50 .7 .........777.. Misc. ........................................................................
....7777...........................
Annual Electrical Maintenance , 7777_........ ... 25.00 .. .............. Permit Fee ..........................................................................$ 6.00
Other (see Ordinance Current) .................. ......._..... ........_...... ......_...... TOTAL PLUMBING PERMIT FEE (plus penalty if app. E]) $
.............
APPLICATION FOR HEATING/COOLING PERMIT
....................................................................................... ........................
Permit Fee --...................................7777....-7777--......7777.-_... $ 6.00 PERMIT INSTALLATION NO. EACH FEE
TOTAL ELECTRICAL PERMIT FEE (plus penalty if app.❑) $.26,0.0 Forced Air Unit...............to 100M -......-............ ......... $ 6.00
INSPECTIONRECORD over 100M .................... ......... 10.00 ...............
Comfort Cooling Unit.....to 3 ton/HP................. ........... 8.00 ...............
Forms / Foundation...........................-- By:.................. Date:................ to 15 ton/HP................ .........- 9.50 ...............
Ground Work ........-............................................................... to 30 ton/HP.......................... 12.00 .......:.......
h Electrical ........................................................................................ to 50 ton/HP................ ......
.... 17.00 ...............
#mbing
e - Plumbing and Heating .............................................................. S ace Heater........ Well Heater .......................... ........ ...6.00 ......Isulation /Ener P
9Y................................................................................... Flues - other than above .................................... ............3.00 ............... ,
GasTest ..............................--........................................--................---- 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 .................................--................. TOTAL Htg./ Coolg. Permit Fee (plus penalty if app. 0) $
Final - Public Works..........VA•h....................:.........
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