S3097 —APPLICANT-TO FILL-IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPIACATION/PERMITPLUMBING-MECHANICAL S 3097
y BUILDING PRIIJECT IIIENTIFICA110N
{UILDIN Il I"S' / �/� /� , �,j�. SANIIAKY NO. API'LICAI'Il1NMl'1'1'Ah UATIi
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ARCHTTECLiENGINF,F.R: LIC NO: ♦ HHV /(/� �(K' 1/ t ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fete Paid by Applicant(Initial) RLDG I!IPCT PLUMB MIECH
❑ ❑ ❑� ❑
LICENSED Con'fknClnR:9 DECLnRA9'l0 QTY ELECRIC PERMIT E 10B DESCRIPTION
1 herehy affirm Ont I am licrnwl under pmvidms of M 9lcmtmercing
QaZ 1hS n-I(I0)o D,, w3onhc Busincvva Pnfcvti .nndmylirenw le RESIDENTIAL
LL1QQ wi PERMIT LCSUANCI!
��_ rn fullC rand ❑SFDWL ❑KDCHEN REMODEL
QUE) Limn- I,n, 0 APPLIANCES-RISIUI-MIAL ❑AUDITION El PLUMBING RE-PIPE
F Z Y: DUB L',notwo
I zW OMUI.T-UNIT ❑SIRUCIURAI.
ARCIIIThe DI!C A
1'ANI!IS MOUIFICATIOR
OZ-
undcntwaJ ntY plwu aWll be uudmpu m t UPT0201AAlIK
El INTERIOR C]CHIMNEY REPAIR
L-'�'-,F"{ciI L'1.en.rrl Profulo,n.1 201-InMANIPS IMPROVEMENT [3SWIMMING POOLS
Lyn; OWNER-BUILD DI!CLARATON OVER RI(0AMPS RATH RHNLDE1JRLPAIR ❑DEXIOLMON
C' Q I hcmhy vPlnn ftr I wn ,,o I fmm th CO,Woca Liecnw law lox Nc
XQ d U fdbwing teanrn(Section 10315,Bowness anti Pmreaion,C«k:Any city or county SIGNS ELECTRICAL ❑OTHER
ts13 W� which rv,uirtx a p¢oro n.1.11,11,vlmr,omprovc,rkna,li,h,«tellil nny,vunuro
F u'0; pnor to its i.suarce.also regwtes Ocapplic-ewf«wch pmnit to likesigrcd mmenent SPECIAL CIRCUFFAIM.
5�y y 'M,he is linen,o,J puruwnnnthe Pro,monnfthe Conn,.....License law OChuptv9
u1��0 (.oa,f,ir,.an Sretinn 1000),&Divmm 3,fde Huaine.wW PrnfeIo.C«klor TEVIP MEYER OR POI.E INS . COMMERCIAL:
dy e thm be is eaemp,derefrom amt Ile look f«the dlOXd cmmgion.Any vinlwien of [IN IIW BLMALLMON ❑DEmo ETON
X m Smtion 11131 5 by any vppllcunt ova perunt xub,.L,the applicunt to a civil pvrI'If MOWER DEVICES EI TENANT ❑FOOD SERVICE
ztrot nem than Eve hundred dollars ISM, IMPROVCMFNT
=d❑ � Lvvrw«+,ftM1c pmlmrtY.«11rycn1pinywvwitll wvgcr a�lhvirmkanmpcnwnm. SWIMMING POOL ELECT
rilltothe w«k,;vv theetntmuaeistog imerelcd,rmfertd f«role(Scc.104J,Busireu OTHER
�3� and ProfFsdna.0«Ic.911,Cot..ry Lire,law dict na apply nr nn rwncr.d OVI'LBIS-SWI'I'OIIIS-TEXTII 5
prole,.win Wilds«imryo.cs th orh cool wW docs such w«k himselr ry Wwgh
his own emphrym,,pmvidcd r I troch i .I,a,cntn om wN Ini nkA or n0cnd Gx NEW RI'SIUFNIIAL ELFCTIt S FT.
If.
hoav+:r,the WiMingmitnTx,vrnem is std withinaryemd mmpktivn.tk SQ.FT.FLOOR ARTA HISQ.I7.
R-th i)0.will hovenlc brNen ofprovingIII,M:didnot thrift mimlmre,for fvr-
,vae of sate). TOTAL:
I,a corner of the ptopcny,ern,votiosely conlowong with Iirenwd cmimov,m
msaoct th project(Sec,IUW.Busimu and PorLvviens Codc:)Inc Contowtorh Li-
te law dot n«vpply t,Inn I..f pcgrny wn,W ikLh,or 1-1111-thereon,and QTY, r P17 FEE
who umwcl.v r«such PmF'rs whh a c«nrucnr(s)Ikmwd purwvnnn I W Crwtrucux'x �(^
licrnw law. PORN NCE � ,-J 0
O Iemcecmpt underSm. .I1R VCI @i,vr,.—
ALTER-DRAIN&VFM- 'T ) VALUATION
w«r Tac
• Moo
coal RS CONIPI NSArvorju[ON or DECIARATIONvolol N W CF,
1 W¢hy o1Rnn utter Morally of pxjury one of the following all—inn':
I hate"will mainuin IrCenificve of CooI It,seir onorc f«WrAer`%C«vpen- DRAINS-ER.00R,ROOF,AREA.CONI STORIES 1'YPECONSTRUCTION
-lion,In,prnvidd for by Section 11001 M tM1 x Cnde,f«ft perh rovowe of the
a,k f« hich this prmil is isaucd. PI1CTUkES-PF,R'1'RAY
Fl I have mol will mwnavIt WMer'. rxerpeel mn Into.e,as required by SeOim
9100 of the 1aMx Cdc-tbr the per n r the work f«whiuh thln pcm,il is isnmd 3M-I IN C.40U'1'LEFS OCC.GROUP APN
My W'Mcrs Compenawon In arcvaric vaW P,Icy number ere:
Cunkc 1'ohcy No.: GAS-IEA.SKSIIJN{1VIER 4(EA)
CERTTFIC ' ;OF EX PI'ION FROM WORKERS' GREASFANDUSIII.WASTE INTERCIEPfOR
OMI'FN TIONINSURANCIE BUILDING DIVISION FEES
(Thissadm rl¢ mtWm elm i(the penNtisf«mehuedrtd JolLn($Igll ORFSF,TRAP --
«kcs.) PhANCIIECK ITE
I mrtify tM1a' orf to Jwl SEWER-SANITARY-STORM EA.201)FL
not employ any min y an ,the WI"t_C«npen- ENERGY FIB:
Z -tion Laws of C' if, )' c m WATI!R HEATER WN N AiLECfR GRADING TEP.
C A,heno
y NOTICE'CO 'PL1 'I': ler nuking thin Ccnifmlc of Uaentptlon.yoo,kOld WATER SYSUF.M/IREATIN'(I
haeme w t m de W« 'Con notion pnwisi,u of t11c lah0x Cade.y«t tmtu SOILS FEE
hnthwilhv lnply with, pro x this pvOrl,oll h dmnetl revoked WAI'BR SERVICE?
Q
5Z CONST SCION LENDINGAGIlJCV NIEW RESIIy1MIALPhMR, SQ.El PAID Uatc xcilxtl
U O herehy� tht ernstrvnim terraingngercy for 0e perf.,,.f
FI k f«which 1ho"1"it 1fasuN(.Sec,:NIYI,civ.CJ TOTAL
I .Nam. .nl.
W Ic cr',Addo,,, _71
I certify that I hove reml Niv applieroon anti woe than tW ahove iof.w.is UUILDING PCE
Nxtect.l agreemwm,Ply wah all coy and marry«dinnrce etW awclaws,Wing to QTY. MECHANICAL PERMIT FRE
U SEISMIC FEEZ haldm,,.n4rucunor vtdnehy havthnrize tcprccmwive,nf this city corn,+urym the
vbnvemeMiard pro toy for inspection potarvi PERMIT ISSUANCH 19SCTRIC ITE
(Wc)ugrtc to a,v.inden rify and kcgr hrinlcu the City or Cupeniixr agai-I
IiJrilide..jutenrcnts,«o.oraleapensesxhieh may iotoy way aa'crvcagorroa id City ALTER OR ADUTO FIECH. PLUMBING FEE
mmqueree o&,he goorong of this Noel.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.00 CFM) MFCHANICAh FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER Mary)CFMI CONSTRUCTION TAX
Sigrmmrc of ApplicvMContractnr Dwc EXHAUST HOOD(WIDUCT) HOUSING MITIGATION FEE
HA7VIRDOUS MATERIALS DISCLOSURUE
WilhWnpplkvm nr forumW 0t`g rxcuFam nom-hwdlc I.doua nwmriw ILEA PING UNIT CIU Igl,M)HTU)
Code,
eSo by the Cupmim Mu - pal CoM.CTuptm 9.12,and the tkwtb aaW Safety
Smtim S532fa)'? I IGTING UNITµNEN I f0,I1fM1 BTU)
❑YesPAID
�i VENfILATIUN PAN(SINGLE RI?SIU) Uotc N«.IIMM
Will Ne vppl' t«[wuaE Wilding uw upmn row cFuPrcvt or devices which IIOILIiR-COATI'(9H1'(1R Ile)Iy0 NTU)
cmil 4',, ,wr c tami.v us rrfi by tic BIiy Mc r Q-1ity Managenent Tdl'A e
INsmcR BOILER-COMP(OVER 100.000 BI U)
❑t'cs
1 vy� oeriat,egonenrnts under Chnpm hq5 or thc Cali- AIR CONDITIONER ISJSUANC17 DATE
tirmiu II�L cry « r liim 255015.255T:roti 3531.1 unr4rvadl tbat if lW NEW RESumINTIAL ht I!CH. SQ.FT.
WiWing Y"' 'catmm,that it is my mpon.vihillrym ufytkocnaPvm
It thi N a frost h fro,lois «cor. f y.
Ow r a1 and egcn - um 'TOIAh: ISSUED BY.
OFFICE