BLD-2023-1643_ApplicationCONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 e permitcenter@cupertino.org PERMIT #B j_D-2oz - t (, t f>
CUPERTINO I REV # DEF a
I —I NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION ❑ T.I. ❑ MEP ❑ RE -ROOF ❑ SWIMMING POOL/SPA
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OWNER NAME
STREET A DRE
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CITY, ATE, ZI p (� °
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CONTRACTOR NAME [IOWNER-BUILDERCOMPANY
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NAME
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LICENSE NUMBER
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LICENSE TYPE
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STREET ADDRESS ff ^ A , k `
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CITY STATE ZIP
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(BUS.
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E-MAIL
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PHONE L40
❑ ARCHITECT ❑ OWNER ❑ OWNER AGENT EICONTRACTOR AGENT [I ENGINEER ❑ DEVELOPER ❑ TENANT
CONTACT NAME
E-MAIL
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTON ---
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TOTAL VALUATION:
❑SINGLE-FAMILY/DUPLEX ❑ MULTI -FAMILY ❑ INDUSTRIAL ❑ COMMERCIAL
USE
TYPE
OCC
SQ.FT.
VALUATION ($)
EXISTING USE
EXISTING SF
NEW FLOOR SF
PORCH
SF I DECK SF
DEMO SF
STORIES #
TOTAL NET SF
REMODEL
BATHROOM SF
REMODEL KITCHEN
SF
REMODEL OTHR
SF
GARAGE ❑ ATTACHED
SF ❑ DETACHED
EXISING ❑ YES
FIRE SPRINKLERS ❑ NO
EICHLER ❑ YES
❑ NO
SECOND STORY ADDITION ❑ YES
❑ NO
DWELLING SECOND DWELLING ❑ YES ❑ ATTACHED [I DETACHED OTHER
UNITS # UNIT ADDITON: ❑ NO S F
POOLS
❑ FIBERGLASS ❑ VINYL -LINED ❑ GUNITE ❑ PREFABRICATED
POOL - SF SPA - SF I SPA ATTACHED ❑ YES ❑ NO TOTAL - SF
Commercial or Multi -Family Buildings with Public Swimming Pools requires Department of Environmental Heath approval
RECEIVED BY:
RE -ROOF
EXISTING ROOF TYPE: BUILT-UP ROOF ❑ ASPHALT SHINGLES Q WOOD SHAKES ❑
WOOD SHINGLES ❑ TILE OTHER (SPECIFY)
REMOVE /REPLACE ❑ NO
❑ YES
I IF NO
# OF LAYERS
PLYWOOD ❑ 'h" ❑ 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 i correct. I have read the Description of Work and verify it is accurate. I agree
to comply with all applicable local inances and state aws lating to building construction. I authorize epresentatives of Cupertino to
enter the above -identified propeIf inspe tion p p es. I knowledge and authorize all information coained on is application form
to be made available for public rd. 2 /
Signature of Applicant/Agent: iM� Date: kA
SUPPLEMENTAL INFORMATION REQUIRED
*New SFD/Second Dwelling Units/Multifamily Dwellings: A Demoliti n 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
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�3 0 Cj S— 1 BldgApp_2017.doc revised 01101121