1877 (2) CITY. OF CUPERTINO
FEB 5 1981 L
PERMIT NUMBER
FOR APPLICANT TO FILL IN
STREET ADDRESS OF PROJECT:
Plans Received By...................................................Date ......................... Legal Description: Tract...............`...�.... �Ipck............ Lot......................
REO.: Plans.... Survey.... Calca: Struc..... Energy.... Elect..... Mach.... Description of Work: .......�.n/y¢r/4L...�O.,L1 .. ..
Plans Checked By............................... Date .... ... Tat Struct. Improvement on Parcel:Yes.... No.VArea of BIdg.O . ./.'
Application A roved B -...........Date ...... .- y
pp pp y......................-.... . /�/- Separate Structure....:....... or Addition/Alta,!p�t/ton to Exist. BII�g�..........
Validated By...........................................-.................Date -....................... No. of Stories.:...../...... Use of Building ..!�/'l.i./yO.P!
Compensation Certificate Verified By....................Date ---................... Valuation of r 'e : $.... l .................................. ...
.....
s • • . . •
$ Owner: ...... . ....GG' 4././YP..uCALp,*Phcne:.J..�1.c Sex
Permit Fee (plus penalty if applicable) ........................$....................... Contractor: . ............................... City Bus.Lic.#................................
Plan Check Fee (less deposit of$.......... Rct. #..........)$....................... Address: ....._.._........call....... ............ ...1�Phone:....................
Contractor - Electrlcal:� ... e..�.. PIton
Energy Plan Check Fee (Dep. of $........ Rot. #........)$....................... �
Strop Motion Fee —.........................................-.........—$.......................
City Busines License #.................... Phone:�J�f:./�..�
Strong ......... Plumbing: ......................................................................................
PlumbingPermit Fee $.....
................................................ City Business License #.................... Phone:....................
Electrical Permit Fee ......................................................$...6r. ...... Heating and Cooling ..................................................................
Mach. Htg./Coolg. Permit $ ..............................$....................... City Business License #.................... Phone:....................
Construction Tax.............................................$....................... Architect/Designer: Phone:....................
Sewer Conn. Fee .............. Water Conn. Fee ..............$....................... Engineer: Phone:.........
g' .................................................................... Unkriiiwii
LandscapeFee .................... Street Tree Fee ............$....................... Lender: ....................................................................................�I..................
Misc. Fee ........................................................................$....................... ............ '•I certify that in the performance of the work for which this penult is
• , , , : $ issued I shall not employ any perso in arty m rte eo m to become sublet(
to the workman's co penaeti le I Celllo e.'
Type Const......... Group........ Div......... Occ. Load........ No. Exits........ SIGNATURE OF
QQJ
Floor Loads: 1st.... 2nd.... Other.... Sprinklered.... Area Sep. Walls.... APPLICANT/OWNER .. z ... . ....I..."....... ...........DATE 4....v.- ...
• • .......-- I certify that as the applicant I am licensed under the prp](IeJons of Ns
Contractors License Law and further that my Licenae No.
Environmental.Status: Exempt............ Other....................... In Classlllcatlon ........................................le in lull force an
/Vie
or
.................
Design Review Approval: Bldg. . Site Sign I certify that I am exempt Item the "Licensed Rao, ad"provisions of
the
--- '-""""- """"" Contractors License Law. (state heals of exemption.,
Use Zone ............ P.D. Conditions ............................................................ I hereby acknowledge that I have read this application and state that the above to
Cond. Use Permit #......Variance #...... Parking Spaces.... Load. Sp..... correct and agree to comply with all City Ordinances and State Laws regulating
rovedBy........................................................... 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 c nsequjpncglof in gr tlog-of this permit.
roachmenl Permit........................ Grant of Easement........................ SIGNATURE OF /� ••��S,�Op
urb, Gutter, Sidewalk,. Driveway: Replace Repair APPLICANT/CONTRACTOR............... .. .! TE.(_..._.._._
Sewer............ Conn. Fee$................ Water................ Meter $................ NOTE: When properly validated Nb form constitutes a Building PamN. Thin
Agreement for Completion of Public Works Improvements .................. permit expires and becomes null and vola should Work not be copervinced Within
Plans Checked By........ Date........ Approved By........ Date.................... Igo day from valldallon dm, or should authorized construction be suspended a
abandoned for s period of 110 days cher work Is commenced. jr.
APPLICATION FOR ELECTRICAL PERMIT
APPLICATION�sim •• PLUME31NG 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 r..rro.... 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/$7.06,-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. $8.00 Ea. add Sys. $2.00....................................
per HP—KW—KVA to 1/$2.00, 5/$3.50, Vacuum Breakers .........n.k .... .F..o..o..r...6,ra.n................ 4.50 .............
20/$0.50, 50/$10.00, 100/$12.00, Slop Sink........ Floor S 4 00
--
4.00
... .................... Urinal.... Interco Water Softener.... ...................... .............
500/$15.00 .............".................................. ......... tor....p
Signs with I XFMR ...................................... ................ 2.00 ................ Plumbing Piping without fixtures .................................. 4.00 ........_...
Eachadditional XFMR/Time Clock .. ................ .50 ................ Misc. ............................................................................................. ........--"'
Annual Electrical Maintenance . ................25.00 .. .............. Permit Fee ..........................................................................$ 8.00
( ) .................. . .............. TOTAL PLUMBING PERMIT FEE (plus penalty if app. p) f
Other see Ordinance Current ............. ................ •
......................................................................... .............................. ...............
APPLICATION •• HEATING/COOLING
Permit Fee ........................................................................ $ 0.00 PERMIT INSTALLATION NO. EACH FEE
TOTAL ELECTRICAL PERMIT FEE(plus penalty If app.O) $ •S—a Forced Air Unit...............to t00M................................. $ 0.00 ...•...••.•••.•
INSPECTION • . , I over 100M .................... ........ 10.00 ..............
Comfort Cooling Unit.....to 3 ton/HP................. .......... 0.00 ..............
Forma / Foundation............................... By:.................. Date:................ to 15 ton/HP................ .......... 9.50 .
..............
0sembingGround Work ............................................................................ to 30 ton/HP..........................12.00 ...........--..
ghElectrical ........................................................................................ to 50 ton/HP.......................... 17.00 ...............
me - Plumbing and Heating .............................................................. Space Heater........ Wall Heater ......................................8.00 ...............
lation /Energy................................................................................... Flues - other than above .................:..............................3.00 ...............
Teat .................................................................................................... Vent Fan: Kitchen........ Bath ..........................................3.00 ...............
Temporary Power Gas / Elect............. Commercial Range Hood 8.00 ...............
Final - Electrical ........................................................................................ Misc. ...........................................................................................................
Final - Building/ Mechanical .................................................................. Permit Fee ........................................................................$ 9.00
Final - Design Review / Landscaping .................................................... TOTAL Htg./ Coolg. Permit Fee (plus penalty if app. Q) $
Final — Public Works..........................:................................