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1918 a PERMIT NUMBER FOR APPLICANT TO FILL IN STREET ADDRESS OF PROJECT: • .....ICPWr........oer.e* dw.p...A/�.. Plans Received By....................................................Date ......................... Legal Description: Tract........................ Block............ Lot.........:-I......... REQ.: Plans.... Survey.... Calcs: Struc..... Energy.... Elect..... Mach..... Description of Work: ..t4Ep.j.l....... ............. Plans Checked By..................................... Date 1st Struct. Improvement on Parcel:Yes.... No.... Area of Bldg............... Application Approved By.................. Elate Separate Structure............ or Addition/Alteration 10 Exist. Bldg........... Validated By..............................................................Date �./................ No. of Stories................ Use of Building .................................................. Compensation Certificate Verified By.................... Date ......................... Valuation of Project: $................................................................................ $ Owner: ...C.1.117t'...CI.F.... .... Phone:.................... Contr�ctor:�ML..I#J.I...4rA.P..P.k4kVCity Bus Lie. 0 Permit Fee (plus penalty if applicable) ..................... -$...................... A --S�j ).-viiso.(,l.......1:4 ................. 6 Plan Check Fee (less deposit of$.-....... Rct- #..........)$....................... Contractor - Electrical: —............ .................................. Energy Plan Check Fee (Dep. of $........ Rct. #........)$....................... City Business License r.................... Phone:.................... StrongMotion Fee ..........................................................$.....? Plumbing: ...................................................................................... Plumbing Permit Fee .......................................... $..... .7- 6.--6 .,. ..... City Business License #.................... Phone:.................... Electrical Permit Fee ......................................................$....—................ Heating and Cooling .................................................................. Mach. Htg./Coolg. Permit $ ..............................$....................... City Business License r.................... Phone%.................... Construction Tax.............................................$....................... Architect/Desi ner: .................................................. Phone:.................... Sewer Conn. Fee .............. Water Conn. Fee ..............$....................... Engineer: .................................................................. Phone:....u6kli6wii LandscapeFee .................... Street Tree Fee ............5....................... Lender: ....................................................................................Q.................. Misc. Fee .......................................................................If....................... ............ "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 at to become subject to the workman's compensation Is"of California." Type Const......... Group........ Div......... OCC. Load........ No. Exits........ SIGNATURE OF Floor Loads: tat.... 2nd....'Other.... Sprinklered.... Area Sep. Walls.... APPL!C�ANVOWNER .................................................................... DATE ........................ I certify that set the applicant I am licensed under the p rihms the Contractors License Lqw and further that Status: Exempt............ Other........................................ In Classification .........C..-.X7............. is in full force and affect:or Design Review Approval: Bldg. ............ Site ............ Sign ............ ............ I certify that I am exempt train the"Licensed Req.'rod" provision of the 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 Is Cond. Use Permit r....„ Variance r...... Parking Spaces.... Load.Sp..... correct and agree to Comply With all City Ordinances and State Laws regulating ApprovedBy......................................................... Date ........................... building. I (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, Jud,girteritejoat and KP which may In my way , r roachment Permit........................ Grant of Easement........................ occurs against said C ty in :Once a ting of thl,�imit. SIGNATUREqq 4pucti, Gutter, Sidewalk,.Driveway: Replace Repair OF ...... APPLICANT/IrOWRACTOR ,.I - lad I _ d th Sewer............ Conn. Fee $................ Water................ Meter $................ hfs�y. 9 NOTE: When properly vall a am cc Thb Agreement for Completion of Public Works Improvements .................. permit expires and becomes null and void should work not be commenced YAM Plans Checked By........ Date........ Approved By........ Date.................... 120 days from validation data, or should authorized construinflon be suspended or abandoned for a period of 120 dans after Work Is commenced. APPLICATION FOR ELECTRICAL PERMIT I APPLICATION FOR PLUMBING PERMIT PERMIT INSTALLATION NO. EACH FEE -- - Light Outlets............Switches............ PERMIT INSTALLATION NO.IEACH I FIEF if Fixtures............ Receptacles............ Gas Sytem with up to 5 outlets ........ .........*­............ $4.00 ............. TOTALNUMBER(lessthan 1000watts).... ................ $ .80 .... ........ 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/$40.06..................... ............ ................................ Sewer ............................................................-.......... 8.0o.? 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, 50/1110.00, 100/$12.00, Slop Sink........ Floor Sink........ Floor Drain ... 4 00 .....I........ 600/$16.00 ............................................... ............ ................ .............. Urinal.... Interceptor.... Water Soft ............ 4.00 ............. Signs with I XFMA ..................................... ............... 2.00 . ............. Plumbing Piping without fixtures ........... 4.00 ............. Each additional XFMR/Time Clock .......... ... .80 ................ Misc. ......... ........****"*'**......*........ ...................... ........ Annual Electrical Maintenance ............ ...25.00 . .............. Permit a ..................................................................... .0.0 ov Other (see Ordinance Current) .................. ............ .—............ .............. TOTAL PLUMBING PERMIT FEE (plus penalty if app. [J) I ........................................................................ ............ ................ .............. APPLICATION FOR HEATING/COOLING PERMIT ..................................................................................... ............... ........... -- - Permit Fee .................................................. ................. $ e.oO PERMIT INSTALLATION NO. EACH FEE TOTAL ELECTRICAL PERMIT FEE(plus penalty If app.(:)) S Forced Air Unit...............to 100M ........................ ...:... $ 8.00 ••--:---:••--- INSPECTION RECORD over 1 DOM .................... ........ 10.00 .............. Comfort Cooling Unit.....to 3 ton/HP................. ........ 6.00 .............. Forms / Foundation............................... By:.................. Date:................ to 15 ton/HP................ ....... 9.50 ........... Plumbing Ground Work ................................ ........................................... to 30 ton/HP................ ......: .12.00 .............. 1-9.ough Electrical ...................................... ........................... to 50 ton/HP................ ....... . 17.00 .............. no - Plumbing and Heating .............................................................. Space Heater........ Wall Heater ......................................e.00 .............. ulation /Energy............................... .................................................... Flues - other than above .................................... ....... ...3.00 .............. as Test ................................................. .................................................. Vent Fan: Kitchen........ Bath .............................. ....... ...3.00 .............. 'lemporary Power Gas /Elect............ .................................................... Commercial Range Hood ... 6-00 .............. '�tal - Electrical ..................................... ................................................... Misc. .......................................................................L........I............I............... '%I - Building/Mechanical ............... ...........................................—*.... Permit Fee ........................................................................$ 6.00 1- Design Review / Landscaping .1......................... I.......................... TOTAL Htg./ Coo1g. Permit Fee (plus penalty If app. C3) III Public Works...........................................................