BLD-2023-2514_ApplicationCONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
[is 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • permitcenter@cupertino.org PERMIT #B 7e S1- ZS `
CUPERTINO REV # DEF #
❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION ❑ T.I. ❑ MEP ❑ RE -ROOF ❑ SWIMMING POOL/SPA
PROJECT ADDRESS K) /� r� /� n { r� jJAPN
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#
OWNERNAME / PHONE
E-MAIL
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STREET ADDRESS / j � 60(.A h� I
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CITY, STA�E, ZIP ,/ vo /� T
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CONTRACTORGNAMIE ❑ OWNER -BUILDER COMPANY
INS LIB
NAME
LICENSE NUMBER
LICENSE TYPE
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STREET ADDRESS �.� /
CITY TATE, ZIPr�
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BUS. LIC �/�®r2-
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❑ ARCHITECT ❑ OWNER ❑ OWNER AGENT CONTRACTOR AENT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTACT NAME L T
E-MAIL
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTON Q- {
TOTAL VALUATION:
❑SINGLE-FANULYMUPLEX ❑ MULTI -FAMILY ❑ INDUSTRIAL ❑ COMMERCIAL
USE
TYPE
OCC
SQ.FT.
VALUATION ($)
EXISTING USE
I EXISTING SF
NEW FLOOR SF
PORCH
SF DECK SF
DEMO SF
STORIES #
TOTAL NET SF
REMODEL
BATHROOM SF
REMODEL KITCHEN
SF
REMODEL OTHR GARAGE
SF SF
❑ ATTACHED
❑ DETACHED
EXISING ❑ YES
FIRE SPRINKLERS ❑ NO
EICHLER ❑ YES SECOND
❑ NO
STORY ADDITION ❑ YES
❑ NO
DWELLING
UNITS #
ISECONE)DWELLING ❑ YES ❑ ATTACHED❑ DETACHED OTHER
UNIT ADDTTON: ❑ NO S F
POOLS
❑ FIBERGLASS ❑ VINYL -LINED ❑ GUNITE ❑ PREFABRICATED
POOL - SF SPA - SF SPA ATTACHED YES ❑ NO TOTAL - SF
Commercial or Multi-Familu Buildings with Public Swimming Pools requires Department of Environmental Heath approval
RECEIVED BY:
RE -ROOF
EXISTING ROOF TYPE: ❑ BUILT-UP ROOF ❑ ASPHALT SHINGLES❑ WOOD SHAKES ❑
WOOD SHINGLES ❑ TILE OTHER (SPECIFY)
REMOVE /REPLACE ❑ NO
❑ YES
I IF NO
# OF LAYERS
PLYWOOD ❑ '� ❑ 3/8" PLYWOOD
THICKNESS ❑ 5/8" OTHER
TYPE:
❑ OSB ❑ CDX OTHER
PITCH:
12
ROOF CLASS
A
PROPOSED ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES ❑ WOOD SHAKES ❑WOOD SHINGLES ❑ OTHER
*Provide a signed copy of the Cupertino's Tear -Off Policy SF #of SQUARES
By my signature below I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I
have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree
to comply with all applicable local ordinan st to laws relating to building construction. I authorize representatives of Cupertino to
enter the above -identified property for ins wledge and authorize all information cont ined o this application form
to be made available for public record. / / Z 2�
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED
*New SFD/Second Dwelling Units/Multifamily Dwellings: A Demolition permit is required prior to issuance of a building permit for all new construction.
*Commercial Buildings: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project.
*Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application.
*HOA-Provide a letter of approval from the Home Owner's Association
.4 O� BldgApp_2017.doc revised 01101121