1221 �J
PERMIT NUMBER'
FOR APPLICANT TO FILL IN
STREET ADDRESS OF PROJECT:
DEPARTMENT 21hg,D e,,TEVra4S GRED �uIT� 105 (o
.............................._..........................................................
Plena Received By...................................................Date .................... .... Legal Description: Tract. ..................... Block............ Lot......................
REO.: Plans.... Survey.... Calcs: Struc... Energy.... Elect..... Mach..... Description of Work: ..TEIIAI:IT-: PR �•/ E1:('(5...-...�•.........
Plans Checked By..................... . . .. Date .. ..... U tat Struct. Improvement on Parcel:Yes.... No.... Area of Bldg...............
.............. _
Application Approved By............. ...'... ....'............Date 3�... .... Separate Structure............ or Addition/Alteration to Exist. Bldg...........
Validated By...............................................................Date ......................... No. of Stories................ Use of Bu ding ..................................................
Compensation Certificate Verified By....................Date ......................... Valuation of Project: $./ai..0.61.Q........................................................
Owner: ..... ...AME(Z-.......................... Phone:....................
Permit Fee jus anal if applicable) Contractor+A.. . LE-r......... City Bus.Lie. e.............
lP penalty PP ) ........................$..�v ... -
aD� Address: ...................................................................... Phone:q!}�.. ?�.7
Plan Check Fee (less deposit of$.......... Rct. #..........)$..✓.!.<............ Contractor - Electrical: .............................................................................
Energy Plan Check Fee (Dep. of $........ Rct. #........)$.......... City Business License #....._............. Phone:....................
Strong Motion Fee ............................:.............................$......... .... Plumbing: ......................................................................................
..
Plumbing Permit Fee ................................................$..... .. City Business License #.................... Phone:....................
Electrical Permit Fee ......................................................$...I...7f. .... Heating and Cooling ..................................................................
Mach. Htg./Coolg. Permit $:.............................$... City Busmes Lic nse #.. ................
.............. Phone:....................
Sewer Conn. Fee .............. Water Conn. Fee ..............$....................... Engineer: .......i�OF... .. Q- Phone:.................
Landscape Fee .................... Street Tree Fee ............$....................... .. .. ........................... Q....Unknown
P Lender:
Misc. Fee ..............................:............ ................$.� ..^' "I the workman's compo performance of the work for which this permit Is
$'� �, y any person In any manner es to become subject
Issued I shall not employ tion laws of C omla"
Type Const......... Group........ Div......... DCC. Load........ . d-•Exits'...... SIGNATURE OF pp�
Floor Loads: 1st.... 2nd.... Other.... Sprinklered.... Area Sep, Wells.... APPLICANT/OWNER ...... .. .... . 7,,-J. ..... .. g ATE. ./z
ZONING ............ I certify that as the applicant I am licensed under the provisions of the
Contractors License Law and further that my License No. ..............._...........
••,- in Cfaireficatlon ........................................is In full force and effect:or
Environmental Status: Exempt............ Other........................................
Design Review Approval: Bldg ' Site Sign I csmly that I am exempt from the"Licensed Rea.'red"previsions of the
9 PP 9• --- 9 •-•- Contractors License Law. (State basis of exemption.,
Use Zone ............ P.D. Conditions ............................................................ I hereby acknowledge that I have mad 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
rovedBy............................................................ Date ........................... building.
urb, Gutter, Sidewalk,. Driveway: Replace I (We) agree st save, Indemnify and keep harmless the g o of Cupertino
• s' s against liabilities, judgments,ca to end ax pensee whi may,In any way
SIGNATURE
against said Cily In co --once Oft gr g of this permit.
croaehment Permit........................ Gra of Easement..P................... sIGNATURE of I !� �� /'
Repair APPLICANT/CONTRALTO ///!!+ .... .. .Z4/.�
Sewer............ Conn. Fee $................ Water................ Meter$................ NOTE: When properly validated this loan constitutes a Building Permit This
Agreement for Completion of Public Works Improvements .................. .permit expires and becomes null and void should work not be commenced a48dn
Plans Checked By........ Date........ Approved By........ Date.................... 120 drys from validation date, or should authorised construction be suspended or
'. APPLICATION FOR ELECTRICAL PERMIT abandoned for■period of 120 dm after work N commenced.
PERMIT INSTALLATIOJ$ NO. EACH FEE I APPLICATION FOR
PLUMBING. PERMIT
Light Outlets............Switches. ........ PERMIT INSTALLATION NO. EACH FEE
Fixtures............ Receptacles./.. ..... Gas Sytem with up to 5 outlets ....................................$4.00
TOTALNUMBER(lessthant OO watts) ..................1 $ •50 M.QQ . 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 .............
SERVICE OR TEMPORARY POWER to ................. 2.00 ............... Lavatory.... Shower Pan.... Bathtub.... Sink.................. 3.00 .............
100 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 ............................................ ............. 4.50 .............
20/$8.50, 50/$10.00, 100/$12.00, $lop-Sink........ Floor Sink........ Floor Drain ................ 4.00 .............
500/$15.00 ............................................................ ................ ...........:.. t ! Urinal.... Interceptor.... Water Softener.... ..........11{I............ 4.00 .............
Plu[n
Sign Eaeihhadditional XFMR/Time Clock .. ................ 2.50 . ..............,.,L , .'Misch?�9_Piping without fixtures ._..... .........__. 4.00 .............
Annual Electrical Maintenance . ................ 25.00 ..............._:: - Pe it Fee ..........................................................................$ 6.00
Other (see ordinance Current) ................................................ .............. TO)'AI: UMBING PERMIT FEE (plus penalty if app. �) $
........................................................................
.. ........................................... Nl+
APPLICATION FOR HEATING/COOLING PERMIT
.................:....................................................................................................
Permit Fee ........................................................................ $ 6.00 PERMIT INSTALLATION NO. EACH FEE
TOTAL ELECTRICAL PERMIT FEE(plus penalty if app.i]) $/7 biLd Forced Air Unit...............to 100M ................................. $6.00
INSPECTION over t00M .................... ........ 10.00 ..............
Comfort Cooling Unit.....to 3 ton/HP................. .......... 6.00 ..............
Forma / Foundation............................... By:.................. Date:................ to 15 ton/HP........................... 9.50 ...............
robing Ground Work ............................. ............................................. to 30 ton/HP.......................... 12.00 ...............
ghElectrical ........................................................................................ to 50 ton/HP.......................... 17.00 ...............
me - Plumbing and Healing .............................................................. Space Heater........ Wall Heater ......................................6.00 ...............
ulatlon / Energy............................... ................................................... Flues - other than above ................................................3.00 ...............
asTest .................................................................................................... Vent Fan: Kitchen........ Bath ..........................................3.00 ...............
Temporary Power Gas / Elect............................................................... Commercial Range Hoop 6.00 ,.
Final - Electrical ........................................................................................ Misc. ......... ...fAll...>.Cl.R.2�1........_......................... ............ ., .
Final - Building/Mechanical .................................................................. Permit Fee ........................................................................$ 6.00
Final - Design Review / Landscaping .................................................... TOTAL Htg./ Coolg. Permit Fee (plus penalty If app. p) $3'Lp•p
Final - Public Works....................... ................ ................