B-2019-0026 Request for Permit ExtensionREQUEST FOR PERMIT EXTENSION
Please e-mail the completed form to
pern-dtcenter@cupertino.org
CUP'ERTIN+
❑ Under Plan Review Process Issued Permit
Building Address:: C / —S C 0 / Permit Number: XL • 0
Owner Name: /
Owner Address: '2 1. -7 l /J t2 x Phone: `
Contact Name:
E-mail Address: W /"6- tZ Lc S J4- A TA c Phone: . y G S' �� l/ b
Reason(s) (please be specific): N / n- f' r_- c 7 i t- �-�
Signature: Date: eT - -7
(CITY OF CUPERTINO USE ONLY)
Yes No
Approval: � ❑ Expired Date: Fee: $
Zi
k21.16D
Revised 7/25/2017