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1488 (3) PERMIT NUMBER FOR APPLICANT TO FILL IN STREET ADDRESS OF PROJECT: 1.4ii�...S;u16-.W..JA.... ........-.................................. Plans Received By..................................................Data ......................... Legal Description. Tract Bl9ck............ Lot...................... REC.: Plans.:.. Survey.... CaIcs: Struc..... Energy.... Elect...:. Mach.... Description of Work:Tract................. '* . ..- e Plans Checked By............................... Date 1st Struct. Improvement on Pa' 1:`1'a . No.... �)rea WB-Idg,......... Application Approved By.................... Date Separate Structure............ or Addition/Alteration to Exist. Bldg........... Validated By..............................................................Date ......................... No. of Stories................ Use of Building .................................................. Compensation Certificate Verified By....................Date ......................... Valuation of Project: $'................................................. $ Owner.��hn....clhm�&Ism......................... pii�54*(04 Contractor: ...-...............--................ City Bus.Lic. is................................ Permit Fee (plus penalty If applicable) ........................$. . ............... Address: ..................................................................... Phone:.................... Plan Check Fee (less deposit of$.......... Act. #.......... $.............. -- Contractor - Electrical: ............................................................................. Energy. Plan Check Fee (Dep. of $........ Act. #........)$....................... City Business License a.................... Phone:.................... StrongMotion Fee .......................................................... . ....... Plumbing: ..................................................................................... Plumbing Permit Fee ................................................ ..... City Business License is................... Phone:.................... ElectricalPermit Fee ......................................................$....................... Heating and Cooling ..........*....................................................... Mach. Htg./Coolg. Permit $ ..............................$....................... City Business License -11................... Phone:.................... Construction Tax.............................................$..... ............ Architect/Designer: .................................................. Phone:.................... Sewer Conn. Fee .............. Water Conn. Fee ..............$....................... Engineer: ................................................................... Phone:.... Unktiowri LandscapeFee .................... Street Tree Fee ............$....................... Lender: ....................................................................................Q.... Misc. Fee ........................................................................$....................... ............ "I certify that In the performance Of the work for which this permit 18 $ Issued I shall not employ any parson In any manner so as to become subject to the workman's compensation lam of California." Type Const......... Group........ Div......... Occ. Load........ No. Exits........ SIGNATURE OF Floor Loads: let.... 2nd.... Other.... Sprinklered---- Area Sep. Wells.... APPLICANT/OW NEFr.(*.A4A .........................DATE ............ I tartly that as the applidliahl I am licensed under the provisions of the Contractors License Law and further that my License No. ............................ and affect: or Environmental Status: Exempt............ Other................................... in Classification........................................is in full force a ....* 'Licensed Req. ad" provisions of the Design Review Approval: Bldg. ............ Site ............ Sign ............ ............ I certify that I am exempt from the ' Contractors License Low. (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 e...... Variance e...... Parking Spaces.... Load. Sp..... correct and agree to comply with all City Ordinances and State Laws regulating ApprovedBy:.......................................................... Date ........................... building. I I (we)agree to save, indemnify and keep harmless the City of Cupertino A. , judgments, costs and expenses which may In any way 11110AVLORI.�111111 • A1011:1ell agairst liabilities achment Permit........................ Grant of Easement........................ occurs against said City in consequence of the granting of this permit. SIGNATURE OF Vo Gutter, Sidewalk, Driveway: Replace Repair APPLICANT/CONTRACTOR ........................................................ DATE .......................... Sewer............ Conn. Fee $................ Water................ Meter $.........------- NOTE: When properly validated this forms constitutes a Building Pianist. This Agreement for Completion of Public Works Improvements .................. permit expires and becomes null and void should work not he commanded vANn Plans Checked By........ Date...:.... Approved By........ Date.................... 120 days from validation date, or should Authorized construction he ruffiefunded Or abandoned for a period of 120 days offer work IS command. APPLICATION FOR ELECTRICAL PERMIT aaaaaaaaaa APPLICATION FOR PLUMBING PERMIT PERMIT INSTALLATION NO. EACH FEE Light Outlets............ Switches............ PERMIT INSTALLATION FEE Fixtures............ Receptacles............ Gas Sytem with up to 5 outlets ................................... $4.00 • TOTAL NUMBER(loss than 1000 watts) .....................$ .50 ................ Each additional outlet ............................................ 1.007 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 -................ 2.010 .. .............. 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 ..................... ............ 8.00. ............. ............. .............................. Sewer ............................................................................ MOTORS,Generators,Welders, Heaters, Lawn Sprinkler Sys. $6.00 Ea. add Sys. $2.011........ ........................... per HP-KW-KVA to 1/$2.00, 5/$3.50, Vacuum Breakers ............................................ 4 . .........­ 20/1116.50, 50/$10.00. 100/$12.00, Slop Sink........ Floor Sink........ Floor n ... 4:'.0 ............. �........... 500/$16.00 ............................................... ........ Urinal.... Interceptor.... Water Softener- ............ 4.00 ............. . Signs with I XFMR ............-........................ 2.00 ................ Plumbing Piping without fixtures ......................I............_4.00. ......................... ......... Each additional XFMR/Time Clock .50 ....- Misc. ......................................................... I ....A Annual Electrical Maintenance 25.00 Permit Fee .........................................................................$ 6.00 Other (see Ordinance Current) .................. .............................. .............. TOTAL PLUMBING PERMIT FEE (plus penalty if app. C]) $Id ............................................-..........I............... ............. ................ .............. APPLICATION FOR HEATING/COOLING PERMIT ..............I..............................-.......................... Permit Fee ......................................................................... $ 6.00 PERMIT INSTALLATION NO. EACH FEE TOTAL ELECTRICAL PERMIT FEE(plus penalty if app.0) $ Forced Air Unit...............to I OOM ................................. $ 6.00 ............... INSPECTION RECORD over loom ............................. 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 ............... '-"h Electrical ..................................... ................................................... to 50 ton/HP.......................... 17.00 ............... Plumbing and Heating .............................................................. Space Healer........ Well Heater .......................... ............8.00 ............... Iffnion /Energy........:...................... .......................-......................... Flues - other than above ................................................3.00 ............... Test .................................................................................................... Vent Fan: Kitchen........ Bath .......................... -I.......I...3.00 ............... Temporary Power Gas / Elect........................... 6.00 .................................... Commercial Range Hood .................................. .........i.. ............... Final - Electrical ..................................... ................................................... Misc. ......................................................................J.......................:.......... Final - Building/ Mechanical ...................................J...............-......... Permit Fee ...................................................... ................$ 6.00 Final - Design Review / L d - - .................................................... -----­***'*'*'*................................ TOTAL Htg./ Coo1g. Permit Fee (plus penalty if app. 0) $ Final - Public Works...........................................................