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1463 (2) _ 10 PERMIT NUMBER , . APPLICANT TO FILL IN STREET ADDRESS OF`PAOJECT; DEPARTMENTONLY / (/ �. 2.1...... .I ". ._ . .. ............................ Plans Received By....................................................Date ......................... Legal Description: Tract........................ Block............ Lot...................... REQ.: Plans.... Survey.... Calcs: Struc... Energy.... Elect..... Mach..... Description of Work: .........:...................................................................... Plans Checked By...................f..... . ..�^S Date ............ tat Struct. Improvement on Parcel:Yes.... No.... Area of Bldg............... Application Approved By..........u .aX..................Date/0.T.9�.�i.�.. Separate Structure............ or Addition/Alteration to Exist. Bldg........... 'Validated By..............................................................Date ............ .. No. of Stories................ Ube of Biding .................................................. Compensation Certificate Verified BY...........ter......Date ...... :.fk. Valuation of Proleet: $...7jL'rD. ............................................................... • . .. , $ Owner:�S�: a �.[....................................... Phone:.................... Permit Fee (plus penalty If applicable) �� ContractortI ..614-10N City Bus.Lic.+................. P h PP ) ........................$. ......... Address:� I.IkA. B#/. S?',....... Phone:. Plan Check Fee (less deposit of$.......... Rcl. #..........)$.... ..S... ._�. ContracttSr���rlcal: ................................... ....../..Y�...... ............................................................... Energy Plan Check Fee (Dep, of $........ Rct. #........)$...............�...s..r... City Business License #.................... Phone:.................... StrongMotion Fee ...................................:......................$...........1.!..Y... Plumbing: ...................................................................................... PlumbingPermit Fee C`^:.,.-................:............$..:.................... ���������•�• City Business License +.................... Phone:.................... Electrical Permit Fee ............................` • •k $....................... ,^�•� ��-�����"- Heatingand Cooling Mach. Htg./Coolg. PermitC$-%�.r......_:,.i- ..:..........$....................... City Business License *.................... Phone:.................... Construction Tax..........'......!......... ..................5....................... Architect/Desi Designer: ., Phone:.................... II , 9 .................................................. Sewer Conn. Fee .............. Water Conft"Fee ..............$....................... Engineer: -.................................................................. Phone:.......... Landscape Fee .................1?S�et T ree Fee ............$...... .....�.... Lender: .................................................................................... Unkriowri Misc. Fee ............................................... ,....................$.....�....., ... - ....._..... "I certify that i1 the performance of the work for which ethisco permit It . ; $ Q issued I shall not employ any person I any mann r so m to become subject to the workmen'.compenaation laws •Calilomi Type Const......... Group........ Div.... ... Occ. Load........ ho. Exits........ SIGNATURE OF Floor Loads: 1St.... 2nd.... Other.... Sprinklered.... Area Sep. WBIIs.... APPLICANT/OWNER ... . ....�DATE S/.. . ....,f:�! REQUIREMENTSZONING ........... I certify that as the spplicent 1 am licensed under the pro alone of the Contractors LICemw Low anofyrthy.1hat my License No. ............................ Environmental Status: Exempt............ Other........................................ in Cla1 certify teailihatiexempt from the"Licensed Req. ad" provisions of the UContractors License Lew. (State bast$ of exemption., callon. �' ..... Is In lull force and effect: or t ad"ReV18W Approval: Bldg. ............ Site ............ Sign ............ Use Zone ............ P.D. Conditions ............................................................ I hereby acknowledge that I have road this application and state 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 •t roved By........................................................... Date ........................... building. I (We) agree to save. Indemnify and keep harmless the City of Cupertino s •• s $ egairst liabilities, judgments, costs and ex nses w ch may in any way secure against said City In consequence o the gra ing of this pe mml roachment Permit........................ Grant of Easement........................ SIGNATURE OF .8 �An . urb, Gutter, Sidewalk,.Driveway: Replace Repair APPLICANT/CONTRALTO ...... OATEIL�. Sewer............ Conn. Fee $................ Water................ Meter$................ NOTE: When Property validated his form constitutes a Building Paz This Agreement for Completion of Public Works Improvements .................. Permit expires and becomes nun and void should work not be eommenteed rltiWr Plans Checked By........ Date........ Approved By........ Date.................... 120 days from validation deft,or should suMorte•d cen•mrclbn be suspended or APPLICATION FOR ELECTRICAL PERMIT abandoned for a Period o/120 days after work M commented. APPLICATION FOR PLUMBING PERMIT PERMIT INSTALLATION NO. EACH FEE Light Outlets............ Switches............ PERMIT INSTALLATION NO. EACH FEE Fixtures............ Receptacles............ Gas Sytem with up to 5 outlets ................................... $ 4.00 ............. TOTALNUMBER(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 ............. 100 amp/$5.00, 200/$7.00, 500/$9.00 Wash. Mach..... Dishwasher.... Garb. DIED................... 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/$6.50, 50/$10.00, 100/$12.00, Slop Sink........ Floor Sink........ Floor Drain .... ............ 4.00 ............. 500/$15.00 ............................................................ ............................... Urinal.... Interceptor.... Water Softener.... ..........1............ 4.00 ............. Signs with I XFMR ...................................... ............- 2.00 ................ Plumbing Piping without fixtures ......................J............ 4.00 ............. Each additional XFMR/Time Clock .. ................ .5o ................ Misc. ............................................................................................. ............. Annual Electrical Maintenance . ................25.00 ................ Permit Fee ..........................................................................$ 6.00 ............... .............. TOTAL PLUMBING PERMIT FEE (plus penalty If app. p) $ Other (see Ordinance Current) ................................. p . .......................................................................... ............................. .............. APPLICATION •. HEATING/COOLING ...................................................................................... ................................ Permit Fee ........................................................................ $ 6.00 PERMIT INSTALLATION NO. EACH FEE TOTAL ELECTRICAL PERMIT FEE(plus penalty If app.❑) $ Forced Air Units..............to 100M ................................. $ 6.00 ............... INSPECTION RECORD over 100M .................... ........ 10.00 ...... ........ Comfort Cooling Unit.....to 3 ton/HP................. ........... 6.00 .............. Forms / Foundation............................... By:.................. Date:................ to 15ton/HP........................... 9.50 ............... _Aktubing Ground Work ............................................................................ to 30 Ion/HP.......................... 12.00 ............... -' gh Electrical ........................................................................................ to 50 ton/HP................ .......... 17.00 ............... a - Plumbing and Heating .............................................................. Space Heater........ Wall Heater ..........:...........................6.00 ............... latlon / Energy............................... ................................................... Flues - other than above ................................................3.00 ............... Was Teat .................................................................................................... Vent Fan: Kitchen........ Bath ..........................................3.00 ............... Temporary Power Gas / Elect............. - Commercial Range Hood „ 6.00 Final - Electricaf ........................................................................................ Misc. ........................................................................................................... Final - Building/ Mechanical .................................................................. Permit Fee ........................................................................$ 6.00 Final - Design Review / Landscaping .................................................... TOTAL Htg./ Coolg. Permit Fee (plus penalty If app. p) $ Final - Public Works...........................................................