BLD-2023-1258_ApplicationCONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
L19 (408) 777-3228 • permitcenter@cupertino.org PERMIT #B - AD ! _L,
CUPERTINO REV# DEF#
❑ NEW CONSTRUCTION ❑ADDITION n AI.TFRAT'Inr1 n T I n r,rrn nnnw M ciAnrar,rTnrn n��r ic,, .
PROJECT ADDRESS n b L
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APN #
OWNER NAME _ /
MAIL
STREET ADDRESS 2 /l 2q5 Oh-PF� /C�
CITY, STATE, ZIP
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CONTRACTOR NAME
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COMPAjNNY NAME
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LICENSE NUMBER LICENSE
TYPE
STREET ADDRESS JISTATE, ZIP �� q
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ARCHITECT ❑ OWNE OWNER AGENT ❑ CONTRACTOR AGENT❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTACT NAME
STREET ADDRESS AMC k5 KWIC
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CITY, STATE, ZIP
PHONE
DESCRIPTON 7���
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TOTAL VALUATION:
SINGLE-FAMILY/DUPLEX ❑ MULTI -FAMILY ❑ INDUSTRIAL ❑ COMMERCIAL
USE
TYPE
OCC
SQ.FT.
VALUATION ($)
E)09TING USE
EXISTING SF NEW FLOOR SF
PORCH
SF DECK SF
DEMO
SF STORIES #
TOTAL NET SF
REMODEL REMODEL KITCHEN I
BATHROOM SF SF
REMODEL OTHR
SF
GARAGE ❑ ATTACHED
SF ❑ DETACHED
EXISING ❑ YES
FIRE SPRINKLERS ❑ NO
EICHLER ❑ YES SECOND
❑ NO
STORY ADDITION ❑ YES
❑ NO
DWELLING
UNITS #
ISECONDDWELLING []YES ❑ ATTACHED❑ DETACHED OTHER
UNIT ADDITON: ❑ NO
S F
POOLS
❑ FIBERGLASS ❑ VINYL -LINED ❑ GUNITE ❑ PREFABRICATED
POOL - SF SPA - SF 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[[:] WOOD SHAKES ❑
WOOD SHINGLES ❑ TILE OTHER (SPECIFY)
REMOVE /REPLACE ❑ NO
IF NO
# OF LAYERS
PLYWOOD ❑'A' ❑ 3/8" PLYWOOD
TYPE:
7PITCHa:
ROOF CLASS
YES
THICKNESS ❑ 5/8" OTHER
❑ OSB ❑ CDX OTHER
12
A
PROPOSED ROOF TYPE: ❑BUILT-UP ROOFM1ASPHALT SHINGLES ❑ WOOD SHAKES ❑WOOD SHINGLES ❑ OTHER
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*Provide a signed copy of the Cupertino's Tear -Off Policy sF��U U #of SQUARES '15 P
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 o and state laws relating to building construction. I authorize representatives of Cupertino to
enter the above -identified property or authorize all information co tained on this application form
to be made available for public reco . — 12.,
Signature Applicant/Agent: Z
of Date: Zu /
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
B1dgApp_2017.doc revised 01101121