1041 (2) Q
CITY OF CUPERTINO • �y►`
APPLICATION FOR COMMERCIAL BUILDING PERMI PERMIT NUMBER O �
AND
CERTIFICATE OF OCCUPANCY c FOR APPLICANT TO FILL IN
00 -BUILDING INSPECTION DIVI810N
STREET ADDRESS OFma"PRMTEMse
Plans Received By... .................... Date .................. Legal Description: Tract.................. ..... Ipck... .....r.... Lot......................
REQ.: Plans.... Survey.... Calcs: Struc..... Energy.... Elect..... Mach.... Description of Work: Mt$,9Gv.�c..
..�.. .-. L.!+�4 .._._.........................
Plans Checked By.................. .... . , .... Date �................ .... 1st Struct. Improvement on Parcel:Yes.... No.... Area of Bldg...............
6��........ .....
Application Approved B .... ... ......Date 7_'.?9..'..B.a Separate Structure............ or Addition/Alteration to Exist. Bldg...........
Validated B "C/- .......... g ...........
By....................................E......................Date ......................... No. of Stories............... Us¢,pf Building
Compensation Certificate Verified By..........._._.._Date ......................... Valuatior„of.Pro'ect $._y1.3
• • • • • Owner: r.-.'.r✓yy . 1149.1�'!..["I ..............._......... Phone:.......
Permit Fee (plus penalty It applicable) p � Contractor:}.51. 7. ..... City Su LIC. #..........
d p... Address�7. J. Al.1S._l�l. ... NYIS. A. hone�f��
Plan Check Fee (less deposit oK ... Ret. #..........)$... ..`R�........_. ..I'....
$;�..... Contractor - ElecVlcal: .......... .........._.................... .................................
Energy Plan Check Fee (Dep. of $�.?....,Rct. #........)$.......... City Business License . .................. Phone:....................
Strang Motion Fee ..........._.....� .. ,pr...... ....$..........�_.Z6. Plumbing:
Plumbing Permit Fee ...........t�. .. .............1........$.......................
�J 1 City Business License #................._. Phone:....................
Electrical Permit Fee .._............_......._...r. ... ._._._._$._...._..............
Heating and Cooling ..................................................................
Mach. Htg./Coolg. Permit $'...............b(...........$........._.......... City Business License #.................... Phone:....................
Construction Tax..................:1...n...................$....................... Architect/Desi Designer: Phone:....................
Sewer Conn. Fee .............. Water Conn./F a ..-...........$_----_--------.._. 9 ......................_..........................
S Engineer: ......_....-.._................._......_.............._........ Phon :.
do
_ _ ...........
Landscape Fee .................... Street Tree`Fee ............$.... ../'- Lender: Unknown
Misc. Fee ..... ....................... $......1,0..._•-r... ..I certify that in the performance of the work for which this permit is
• • . $ /y v p lasted I shall not employ any person if any manner so as to become subject
to the workma*ae
tion laws 1 alifornle."
Type Const......... Group........ Div......... Occ. Load........ No. Exits........ SIGNATURE OF //JJ
Floor Loads: 1st.... 2nd.... Other.... Sprinklered.... Area Sep. Walls.... APPLICANT/OWNER ..................... ... . DATE
....� I certify that pplicant I am licensed under the protons of the
• ' Contractors Litem•se w,Apd further that my License Nofj.Vv.2-4...-F...
Environmental Status: Exempt ............ Other......................................
in Cl...iflcafloa .5�.. Jx....................... Is In full force and effect: or
. . ,
Design Review Approval: Bldg. Site Sign I certify that em exempt fromStat the "Licensed Rtion., tl" provisions of the
"."'"'.."' "".......' ...."".""" Contractors License Law. (State baste of exemption.,
Use Zone ............ P.D. Conditions ....................................... ... I hereby acknowledbe that I have read this application and state that the above le
.................
Cond. Use Permit #....-. Variance #...... Parking Spaces.... Load. Sp..... correct and agree to comply with all City Ordinances and state Laws regulating
ApprovedBy..__.................._..._............................ Date ................. ...... building.
• • .�,y,„ I we) agree to save, indemnify and keep harmless the City of Cupertino
• against liabi l i ti as, )udgm nts, costs and expenses which may in any way
acture against said City nce of the granting of this ermi{.
/ g g ///
Encroachment Permit... .... Grant o1 Easement............ SIGNATURE of ````
Curb, Gutter, Sidewalk,. Driveway: Replace Repair APPLICANT/CONTRACTOR ... .. ..... .... ... .... ...... ......... DATE J.. .1.7. .R{:.:..
Sewer..........-. Conn, Fee $................ Wafer................ Meter $................ NOTE: When properly validated Is form constitute• a Building Permit This
Agreement for Completion of Public Works Improvements .................. permlt expires and becomes null and void should work not be commenced within
Plans Checked By........ Date........ Approved By........ Date.................... 120 day from validation date, or should authorized construction be suspended or
abandoned for a period of 120 days after work Is commenced.
PERMIT INSTALLATION NO. EACH FEE • e
Light Outlets............ Switches............ PERMIT INSTALLATION NO. EACH FEE
Fixtures............ Receptacles............ Gas Sytem with up to 5 outlets ................................... $ 4,00
TOTAL NUMBER(less than 1000 watts) ............._.....$ .50 - .... Each additional outlet ................ ........I.......... 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, Slop Sink........ Floor Sink........ Floor Drain .... ............ 4.00..............
500/$15.00 ................................._........... .._....._..-...._......................... Urinal.... Interceptor.... Water Softener.... .......... ............ 4.00 .............
Signs with I XFMR ..............__................
..... ........_...... 2.00 _ ...-.......... Plumbing Piping without fixtures ...................... ............ 4.00
.............
Each additional XFMR/Time Clock .. .._._.._..... .50 .. .............. Misc. _........................_.................................................... .
..........................
Annual Electrical Maintenance . .............._25.00 .. ......._..... Permit Fee ........................................................................$ 6.00
. .
Other (see Ordinance Current) .................. .............. .....................:......... TOTAL PLUMBING PERMIT FEE (plus penalty if app. 0) $
........................................................................ ._........
..................................
• • • ••
.........................
Permit Fee ........................................................................ $ 6.00 PERMIT INSTALLATION NO. EACH FEE
TOTAL ELECTRICAL PERMIT FEE (plus penalty if app.E]) §
Forced Air Unit...............to 100M ........................ ......... g 6.00 ...............
• - • • • Over 100M ............................. 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 ---------------
ugh Electrical ........................................................................................ to 50 ton/HP................ .......... 17.00 ...............
me - Plumbing and Heating .............................................................. Space Heater........ Well Heater ........_..............._.........6.00 ...............
Isulation / Energy................................................................................... 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. .......................................................................I.........I............I...............
Final - Building/ Mechanical .................................................................. Permit Fee ........................................................................$ 6.00
Final - Design Review / Landscaping .................................................... TOTAL Htg./ Coolg. Permit Fee (plus penalty if app. p) $
\ Final - Public Works...........................................................