1809 (2) 11
ITY OF CUmRTI )D
JAN 5 1981 PERMIT NUMBER /dd71
FOR APPLICANT TO FILL IN
i... S ET ADDRESS OF PROJECT:
Plans Received By..:............:....................................Date ......_................. Legal Description: Tract....................... Block............ Lot......................
REO.: Plans.... Survey.... Calcs: Struc..... Energy.... Elect..... Mach..... Description of Work: .......l.,.r&44. l....... ....//...........................
Plans Checked By....................................................Date -................ ... Tat Struct. Improvement on Parcel:Yes.... No....Area of Bldg......:........
Application Approved By.........................................Date ......................... Separate Structure............ or Addition/Alteration to Exist. Bldg...........
ValidatedBy..............................................................Date —...................... No. of Stories......./...... Use of Building ..................................................
Compensation Certificate Verified By....................Date ............-........... Valuation of Project: $.............................................................................:..
•. • .. � $ Owner: . !.<-� Q-......4..5...... ........ P16d.f"............
Contractor:/....�.L/f .?�-:>!.. . City us.Lic.�r.................'..............
Permit Fee (plus penalty if applicable) ........................$....................... Address:A as y-. Phone:'TQr-r
. .�.a?<........._✓.....-N.!r1!....... .. .........
Plan Check Fee (less deposit of $.......--- Rct. #.--.......)$....................... Contractor - Electrical: .....................
Energy Plan Check Fee (Dep. of $........ Rct. #........)$....................... City ,
Bus)''nass License 0. ........ Phone:....................
mbing: 2.-7lJ,e
Strong Motion Fee ..........................................................$..................... Plu *t;,....,/P�6...
Plumbing Permit Fee ................................................$.1.2 tVD...... City Bu ness License e/s};e..... Phone:.:t✓ . .,�
Electrical Permit Fee ......................................................$....................... Heating and Cooling ..........................................:.......................
Mach. Htg./Coolg. Permit $ ..............................$....................... City Business License #.................... Phone:....................
Construction Tax....................:........................$....................... Architect/Designer: Phone:....................
SewerConn. Fee .............. Water Conn. Fee ..............$...................... Engineer: ............................................................ Phone:.... ...........
nknown
LandscapeFee .................... Street Tree Fee ............$..........-............ Lender: .....................................---............................................ ..................
Misc. Fee ........................................................................$....................... ............ "I certify that in the performance of the work for which this permit Is
issued I shell not employ any person In any manner so as to became nDiM
to the workman's comp satlon laws of California."
Type Const......... Group........ Div......... Occ. Load........ No. Exits........ SIGNATURE OF �J� -
Floor Loads: 1st.... 2nd.... Other.... Sprinklered.... Area Sep. Walls.... APPLICANT/owN ,�r.AZ............DATE �F°:.....
REQUIREMENTS I certify the" the applicant I am licensed under the prpvislons of the
ZONING Contractors License Lew and further that my License No.Jr.b.Cei.D_.....
Environmental Status: Exempt............ Other............................... In Classification ........47.CT.!._..._....... Is In full to" and affect:or
......... -
ed
he
Design Review Approval: Bldg. Site Sign I certify thators ilcen9e exempt
(State thesis lot exemption.,
Use
provisions of the
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
Approved By............................................:.............. Date .........:................. building. ,
1,(we) agree to save, Indemnify and keep harmless thaZily of Cupertino
�( s• • against liabilities, judgments,costa and ex pensee h may In any way
acture against said City'In cones of the gr n- g of t;le permit:
oachment Permit.......:...............: _
Grant of Easement.....:::..:.:,... '.... SIGNATURE OF '• Q
urb, Gutter, Sidewalk,.Driveway: Replace Repair pppucaNr/coNTRACTO .. ms w- tutu •_ ATe _/
r Sewer............ Conn. Fee $............:... Water................ Meter$............... NOTE: when properfY v d this toeuilddsg - 11sN
Agreement for Completion of Public Works Improvements .:................ permit expires and baepmn null and volrl Mould work not be eommmee0 sdtlda
Plans Checked By........ Date........ Approved By.......:Date..:'.::.:.....:.... 120 days from validation date.or should authorlsad,eonstruetlon b•'suspsMed as
abmdonad fore period of 120 days after work Is coromanud..};';':::` !
APPLICATION • • ELECTRICAL PERMIT .1 .1
APPLICATION •• PLUMBING PERMIT
PERMIT INSTALLATION NO. EACH FEE
Ligh' Outlets............ Switches............ . PERMIT INSTALLATION "` s"`• NO. EACH - 'FEE
Fixtures............ Receptacles............ Gas Sytetn with up to 5 outlets .................:.:... .......... $4.00 .............
TOTALNUMBER(lessthan1000watts) ....................$ .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.1 Water Heater..! Ld. Tray..:.H.....-1... 4.00 _-Z........
SERVICE OR TEMPORARY POWER to .. . ... 2.00 ............... Lavatory. Shower Pan.... Bathtub.... Sink............:...:. "3.00 ...
100 amp/$5.00, 200/$7.00,-600/$9.00 Wash. Mach..... Dishwasher.... Garb. Disp..... .............. 3.00 -............
900/$20.00, 1200/$40.00 .................................. ............................... Sewer .............................................................................. 8.00. .............
MOTORS,Generators,Welders, Heaters, Lawn Sprinkler Sys. $6.00 Ea. add eye. $2.00......... ..........................
Vacuum Breakers .:....................:................:. : ... ...:.4 50 ....
per HP—KW—KVA to 1/$2.00, 5/$3.50, --,� . ---•••
20/$8.60, 60/$10.00, 100/$12.00, Slop,Sink....'. Floor Sink........ Floor Diein' ....."...:. .:'4.00 ...14%,
500/$15.00 ............................................................ ..............V
...... Urinal:... Interceptor.... Water Softener:.:: ._'.::::....::...:.... 4.00 ...:-........
Signs with I XFMR ...................................... ................ 2.00 ..... Plumbing Piping without fixtures .....................-�.....:.......4:00 .--'--......
Each additional XFMR/Time Clock .. ................ .90 ..... Misc. ......................................................................
Annual Electrical Maintenance . ................25.00 ..... - Permit Fee ........................................:........................:.::...::$Other (see(see Ordinance Current) ..............................:............... ...... TOTAL PLUMBING PERMIT FEE (plus penalty If app.
.......................... ...... APPLICATION •• ss _
Permit Fee ........................................................................ $ 6.00 PERMIT INSTALLATION NO. EACH ' FEE
TOTAL ELECTRICAL PERMIT FEE(plus penalty if app.p) $ Forced Air Unit...............to'100M ..................:......:::._'.: $'e.00 .---:-
INSPECTION RECORD over 100M.................... ...:.... 10.00 ......---.....
Comfort Cooling Unit.....to 3 ton/HP...........:.... ......:... 6.00 ..............
Forma / Foundation.............................: B Date:........ to 15 ton/HP............................9,50
..................
Plumbing Ground Work .......................... ...................7.-.>tR•:.�?A..... to 30 ton/HP............:.............12.00 ......:........
- Rough Electrical ........................................................................................ to 50 ton/HP.......................:..17.00 ...............
9 - Plumbing and Heating ........................:.....:................:.............. Space Heater........ Wall Heater ..............................::...._a.oll ................
atlon /Energy............................... ................................................... Flues - other than above ................................................3.00 .............7
eS Test .....:..........
....................................................................:............... Vont Fan: Kitchen........ Bath ..........................................3.00 ...............
Temporary Power pas / Elect............. Commercial Range Hood 8.00 „-•,,,----„•,
rFinal . Electrical ........................................................................................ Misc. ...........................................................................................................
Final - Building/Mechanical .......7......................................................... Permit Fee ........................................................................$ 6.00
Final - Design Review / Landscaping1........................
TOTAL Htg./ Coolg. Permit Fee (plus penalty if app. p) $
'Final — Public Works...........................................................