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NO PERMIT NUMBER (2) PERMIT NUMBER FOR APPLICANT TO FILL IN STREET ADDRESS OF PROJECT: • M ............. 4...0.4f,4..3.!�.......... ............ ..... ............. Plans Received By....................................................Date ....................... Legal Description, Tract.. .................... Block............ Lot...................... REQ.: Plans.... Survey Cacs, Struc. Energy---- Elect..... Mach..... Description of Work: A � � A.L........................ Plans Checked By......Survey.... ... . ..............Date tat Struct. Improvement on Parcel:Yes.... No.... Area of Bldg............... Application Approved By.............. 3IL31PI Separate Structure............ or Addition/Alteration to Exist. Bldg........... Validated By..............................................................Date ......................... No. of Stories................ Use of Buildin ..... ......................................... y . . Compensation Certificate Verified By....................Date ......................... Valuation of Project: $.......1.4.1.3. . ...................... ................... wffnyne , s • • s $ Owner: ........;04.................................................... Phone:.................... 4.Vilff..... Phone% -0 7? Contractor* .V709- 1A.8. .Z_ .......... .Wit SUP.Lic. 0--- Permit Fee (plus penalty if applicable) ..................... ... .... ......... Address: 47� Plan Check Fee (less deposit of $.......... Rct. #..........) .. .............. Contractor - Electrical: ............................................................................. Energy Plan Check Fee (Dep. of $........ Ret. #........)$.... ........ ... City Business License a.................... Phone:.................... StrongMotion Fee ..........................................................$....................... Plumbing: ...................................................................................... Plumbing Permit Fee ......I.........................................$.....­...... ......... City Business License e.................... Phone:.................... .................. ...................... Electrical Permit Fee ......................................................$....................... Heating and Cooling .........................................A.. Mach. Htg./Coolg. Permit $ ..............................$....................... City Business License e.................... Phone:.................... ConstructifA Tax............ $....................... 'Architect/Designer: .................................................. Phone:.................... Engineer: .................................................................... Phone:................. Sewer Conn. Fee .............. �ia Water Conn. Fee ..............$...................... Landscape Fee .................... Street Tree Fee ............$....................... Lender: ................................................................................. lnown ................* Misc. Fee .................................................................. $...................... ..... "I certify that In the performance of the work for which this permit is �K011f--IM2;lqE, $ Issued I shall not employ any person in any manner so as to become subject to the workman's co3Wmitation laws I C life I&-. Type Const......... Group........ Div......-. Occ. Load........ No. Exits........ SIGNATURE OF Floor Loads: tat.... 2nd.... Other.... Sprinklared..-- Area Sep. Walls.... APPLICANVOWNER .......DATE �11�c cid's ...... I cartily that as the applicant I am to under the p"I 5.0f-me ZONING REQUIREMENTS Contractors License Loa and further that my License No. Environmental Status: Exempt............ Other..................................... In Classification ..........rJ........................ Is In full force and effect: or ............ I certify that I am exempt from the "Licensed Req.',ed" provisions of the Design Review Approval: Bldg. ............ Site ............ Sign ............ Contractors License Low. (State bale of exemption., Use Zone ............ P.D. Conditions ............................................................ I hereby acknowledge that I have read this application and state that the abones, 18 Cond. Use Permit M...... Variance y...... 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, judgments, costs and expanses which may In any way acture against said City In consequence of granting of this permit. WCroachment Permit........................ Grant of Easement........................ SIGNATURE OF Curb, Gutter, Sidewalk Driveway: Replace Repair APPLICANT/CONTRACTOR pp�.... DATE Sewer............ Conn. Fe2$................ Water................ Meter$................ NOTE: When property validated this farm ceiretiallites a Building PomdL This Agreement for Completion of Public Works Improvements .................. permit expinee and becomes null and said shout! work not be cominhanceal will Plans Checked By........ Date........ Approved By........ Date.................... 120 days from valladian data, or should autfunritted construction be suspended Or i . abandoned for a period of 120 days after work In conunimened. -'-f APPLICATION FOR ELECTRICAL PERMIT I i " -morm EACH 1-ttz APPLICATION FOR PLUMBING PERMIT PERMIT INSTALLATION N Light Outlets............ Switches............ PERMIT INSTALLATION I NO. EACH FEE ; Fixtures............ Receptacles............ Gas Sytem with up to 5 outlets ....................................$4.00 ............. TOTALINUMBER(lessthan 1000watts).... ......... ....$ .50 . . ... 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. ............. too amp/$5.00, 200/$7.00; 600/$9.00 Wash. Mach..... Dishwasher....Garb. Disp..... .............. 3.00 ............. 800/$20.00, 1200/$40.00 .................................. Sewer .............................................................................. 8.00. .............. MOTORS,Generators,Welders,Heaters, 4;iil Lawn Sprinkler Sys. $6.00 Ea. add Sys. $2.01[t..:................... ............. per HP-KW-KVA to 1/1112.00, 6/$3.60, Vacuum Breakers ............................................ 4.50 .............. 20/$6.50, 60/$10.00, 100/$12.00, Slop Sink........ Floor Sink........ Floor 6`rain ... 00 :............. 500/$15.00 ............................................... ............ 1!.............................. Urinal.... Interceptor.... Water Softener.... ...................... 4.00 ............. Signs with I XFMR ...................................... 2 Plumbing Piping without fixtures ......................I........1.. 4.00 ........ Each additional XFMR/Time Clock 100, ...... ...........*....*.... Misc. ....................................................................... , . ............. Annual Electrical Maintenance .......I........25.00 ..1........ ..... Permit Fee ..........................................................................III 8-00 Other (see ordinance Current) ................................ . ..*....... ...... TOTAL PLUMBING PERMIT FEE (plus penalty If app. 0) It ..................................................................................... APPLICATION FOR HEATING/COOLING PERMIT ......................................................................... ............. Permit Fee ....................................................................... $ 6.00 PERMIT INSTALLATION NO. EACH 7-F-ET' TOTAL ELECTRICAL PERMIT FEE (plus penalty It app.EI) III Forced Air Unit...............to 100M ........................ ........ $ 6.00 ................ INSPECTION RECORD over LOOM .................... ........ 10.013 ............... Comfort Cooling Unit.....to 3 ton/HP................... .......... 6.00 .............. k forms / Foundatioll............................... By:.................. Date:................ to 15 ton/HP................. .......... 9.50 ...........- t1 ..... ..... ,_ Plumbing Ground Work ............................................................................ to 30 ton/HP..........................12.00 .......... i'v_siiiik—cith Electrical ................................... ................................................... to5oton/HP........................... 17.00 ............... Plumbing and Heating .............................................................. Space Heater........ Wall Heater ........................................6.6 ............... ,ulation /Energy............................... ................................................... Flues - other than above ................................................3.00 ................ Pas Test ...............;........................................4........................................... Vent Fan: Kitchen........ Bath ................... 3.00 ,,,_,_•„•..,• :............ Temporary Power Gas / Elect.................................................................................................................. Commercial Range Hood ....................... 600 '­....... Final - Electrical ........................................................................................ Misc. ......................................................................................4.................... 'Incl - Building/Mechanical .................................................................. Permit Fee ....................................................... .........$ 6.00 Ifilal - Design Review / Landscaping ....................................................J TOTAL Htg./ Coolg. Permit Fee (plus penalty If app. 0) $ let - Public Works...........................................................