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1345PlaRED.:Survey. CaIcs: Struc ..... Energy.... Elect....- Mach Peons Checked B JWW Date .... Date �./ *,/ ' .. Application Approved By ....... .. .. .. - f� r�o ValidatedBy ......................... : ..... - ............................ Date ......................... Compensation Certificate Verified By .................... Date ......................... IIIIIIII&VAIIIII-1111LOM111 -• $ Permit Fee (plus penalty if applicable) ........................ $....................... Plan Check Fee (less deposit of $.......... Rct. #..........) $ ............. Energy Plan Check Fee (Dep. of $........ Rct. #........) $....- .......... .... Strong Motion Fee ..................... C-, f ...... $ ........ ......... 7 41 Plumbing Permit Fee ............... ................................. ..... Electrical Permit Fee .................... r...........19&13...... $..../,Q..". - Mach. Htg./Coolg. Permit $ ..r..... I ...................... Construction Tax ............................................. $ .. .. . ...... .. - Sewer Conn. Fee .............. Water Cpnn&Fe4....D ..... $....................... Landscape Fee .................... StreaeTirtie Fee ............ $....................... Misc. Fee ................................... .................................... S ....................... Type Const......... Group........ Div......... Occ. Load........ No. Exits........ Floor Loads: tat.... 2nd.... Other.... Sprinklered .... Area Sep. Walls.... ZONING REGUIREMENTS Environmental Status: Exempt............ Other ........................................ Design Review Approval: Bldg ............. Site ............ Sign ............ Use Zone ............ P.D. Conditions ............................................................ Cord. Use Permit #...... Variance #...... Parking Spaces.... Load. Sp..... &roved By ........................................................... Date ........................... l roachment Permit ........................ Grant of Easement........................ quclb, Gutter, Sidewalk, Driveway: Replace Repair Sewer............ Conn. Fee $ ................ Water................ Meter $................ Agreement for Completion of Public Works Improvements .................. Plans Checked By........ Date........ Approved By........ Date .................... PERMIT INSTALLATION NO. EACH FEE Light Outlets............ Switches............ $ e.00 ....... 1.00 4*00 Fixtures............ Receptacles............ Comfort Cooling Unit ..... to 3 ton/HP ................. ..... ... .. 6.00 TOTAL NUMBER (less than 1000 watts) ... ............. .... S 50 ........... Range........ Cooking Unit........ Oven.. ...... .. ..... -- ... .... 2.00 ............... 3.00 Dryer.... Garb. DIED-- Dishwasher .... ........ ............. .... 2.00 ............... 3.00 SERVICE OR TEMPORARY POWER to... ..... .... 2.00 .............. too amp/$5.00, 200/$7.00,-500/$9.00 ............ ............... PermitFee ........................................................................ 800/$20.00, 1200/$40.00 .................................. ............................... 4.50 MOTORS, Generators, Welders, Heaters, 00 per HP-KW-KVA to 1/$2.00, 5/$3.50. ... 4.00 20/$6.60, 50/S10.00, 100/$12.00, 7..1 .... ... 4.00 500/$15.00 ......................... ...... .............. ........... Signs with I XFMR ...................................... Each additional XFMR/Time Clock .......... Annual Electrical Maintenance .............. Other (set Ordinance Current) PermitFee ....................................................................... $ 6.00 TOTAL ELECTRICAL PERMIT FEE (plus penalty if app. C]) $ Forms / Foundation ............................... By:.................. Date:................ ,&umbing Ground Work ......................... .... .................. ........................... ghElectrical ..................................... ........................ ........................... -lume- Plumbing and Heating ........... ........................ ........................... lation / Energy ............................... ......................... ........................... GasTest ................................................. ........................ ....................... ... Temporary Power Gas / Elect . .......... ........................ ........................... Final- Electrical ........... ............... ........ ........................ ........................... Final - Building / Mechanical ............ .. ........................ ........................... Final - Design Review / Landscaping I ........................ I ........................... Final - Public Works ........................................................... .16, PERMIT NUMBER 1 13 STREET ADDRESS OF PROJECT: ................................... Legal Description: Trac .................... Block............ Lot...................... Description of Work: 1st Struct. Improvement on Parcel: Yes.... No&rArea of Bldg ............... Separate Structure............ or Addition/ Alteration to Exist. Bldg........... No. of Stories....../....... Use of Building ...... . .... ... . .. Valuation of Pro ct: �v .. CD .... . ... * ...... Owner,77P2ve .... .. Phone: .................... Contractor .......feX .... City Bus. Lic. Address: Contractor Electrical:.... ...................................... City Business License #.. .................. Phone:.................... Plumbing:........-� -.9 /v f ..................................................... City Business Lice se * .................... Phone: .................... Heating and Cooling ....................... ................................................ ........ City Business # .................... Phone:.................... Architect/Designer:............ ....................... Phone:.................... Engineer: . ............................. ..... - - ------- Phone, know. Lender: .................... ............................................................... . .................. "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 w to become subject o the workman's compensation laws of California." SIGNATURE OF APPLICANVOWNER ... -- ............................................................. DATE ................ . .... .4e.."jcertify that as the applicant I am licensed under the prqvlslom I the Contractors License Law and further that my License No,61-F.Ul L -M in Classification ........................................ Is In full force and affect: or I certify that I am exempt from the "Licensed Fee, •ed" provisions of the Contractors License Law. (State Deals of exemption., I hereby acknowledge that I have read this application and state that the above Is correct and agree to comply with all City Ordinances and Sims Laws regulating building. I (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may In any way accure against said City in u I th ranting of this permit. SIGNATURE OF APPLICANT/CONTRACTOR . . . . . .... .... . . DATE NOTE: When property validated this form constiltutas a Building Permit, This permit expires and becomes null and void should work net be cameneseced firliftliff 120 days from validation data, or should Authorized constrecUlan be responded or abandoned for a period of 120 days after work Is commenced. Gas Sytem with up to 5 outlets .......................... ... . I ... $4.00 Each additional outlet ........... ...................... ...... $ e.00 ....... 1.00 4*00 Water System (Installation, Alt. or Repair) ..........1... Comfort Cooling Unit ..... to 3 ton/HP ................. ..... ... .. 6.00 Water Closet.... Mter Heater.... Ld. Tray ............./.... .. .............. 4.00 Lavatory.... Shower Pan.... Bathtub.... Sink......-.......... to 50 ton/HP ... Space Heater.../... Wall Heater 1.zr.6 ..... ....... 3.00 Wash. Mach..... Dishwasher.... Garb. Disp ..... .... ......... ... 3.00 3.00 Sewer.................................................................... ......... Commercial Range Hood .................................. ........ 8.00 Lawn Sprinkler Sys. $6.00 Ea. add Sys. $2.00 ...................... ............ ............... PermitFee ........................................................................ Vacuum Breakers ................................... [Z TOTAL Htg./ Coolg. Permit Fee (plus penalty If aPP. 4.50 Slop Sink........ Floor Sink........ Floor 00 Urinal.... Interceptor.... Water Softener ... ... 4.00 ........... Plumbing Piping without fixtures ........... .......... ... 7..1 .... ... 4.00 Misc. ....................................................................... ) ......... I ........ PermitFee .............................................. ........................ TOTAL PLUMBING PERMIT FEE (plus penalty If app. 1771) PERMIT INSTALLATION NO. I EACH FEE Forced Air Unit ............... to 100M ................................. $ e.00 ....... over 100M ............................ 10.00 .......... Comfort Cooling Unit ..... to 3 ton/HP ................. ..... ... .. 6.00 to 15 ton/ HP ................ ......... .. .............. to 30 ton/ HP ... ............ 1117:20'OL] to 50 ton/HP ... Space Heater.../... Wall Heater 1.zr.6 ..... ....... 8.00 Flues - other than above .........0 .......................... ......... ... 3.00 Vent Fan: Kitchen....... Bath .............................. ............ 3.00 I Commercial Range Hood .................................. ........ -- 6.00 ............... Misc. - ............. ................... . ................................. ......... ............ ............... PermitFee ........................................................................ $ 0000 TOTAL Htg./ Coolg. Permit Fee (plus penalty If aPP. 0) * 4a dv