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10030106 Extension Request Revised 7/25/2017 REQUEST FOR PERMIT EXTENSION Please e-mail the completed form to permitcenter@cupertino.org Under Plan Review Process Issued Permit Building Address: ____________________________________ Permit Number: _______________ Owner Name: ________________________________________________________________________ Owner Address: ____________________________________ Phone: __________________________ Contact Name: _______________________________________________________________________ E-mail Address: ______________________________ Phone: _________________________________ Reason(s) (please be specific): __________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Signature: __________________________________ Date: _________________________________ (CITY OF CUPERTINO USE ONLY) Yes No Approval: Expired Date: ___________________ Fee: $ _______________ X 243 Extended unitl 1/16/2024 upon payment of the fee.