BLD-2022-0338_Extension RequestC1 T Y
REQUEST FOR PERMIT EXTENSION
Please e-mail the completed form to
perniitcenter@cupertino.org
PST.
❑ Under Plan Review Process
Building Address: ' ZL LV
Owner Name:
❑ Issued Permit
Permit N
umber' -,ma --c_R3b
Owner Address: l�C. .� `F Imo/ �C ��- 1, ln�Phone: ` O Cif
Contact Name:�-
E-mail Address: \cam i (�`�L (I ldp� Phone: AM J ) (_7 12,—
Signature: f fl (fin ��i Date: , J
(CITY OF CUPERTINO USE ONLY)
Yes No
Approval: ❑ Expired Date: Fee: $
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Revised 7/25/2017