BLD-2023-2686_ApplicationCONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • permitcenter@cupertino.org PERMIT #B -
CUPERTINO I REV# DEF#
❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION ❑ T.l. ❑ MEP W RE -ROOF ❑ SWIMMING POOL/SPA
In
PROJECT ADDRESS I L^ `, L i, i D I L A 4 j
APN #
OWNER NAME
STREET ADDRESS n r qq Iy , j (
CITY, STATE, ZIP
em�� , `M./ 9 /V iq
CONTRACTOR NAME ❑ OWNER -BUILDER COMPANY
NAME 1
LICENSE NUMBER LICENSE
TYPE
STREET ADDRESS 1 V Vo : uL e, t `� V� ,
' \`
CITY, STAT
, ZIP `1� 9 �' ^
E-MAIL Y'Ci'(-6 G T1 h 41 k 6 a , L v
PHONE t (`, V LJ(J IV d
�L
BUS. LIC I 0 0' 3 2-
❑ ARCHITECT ❑ OWN OWNER AGENT ❑ CONTRACTOR AGE'NT❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTACT NAME
E-MAIL
STREET ADDRESS
CITY, STATE, ZIP PHONE
DESCRIPTON � ,� O 1
LM A041- `(L r 'ilM (DCjl�i P
TOTAL VALUATION:
SINGLE-FAMILY/DUPLEX ❑MULTI-FAMILY ❑INDUSTRIAL ❑COMMERCIAL
USE
TYPE
OCC
SQ.FT.
VALUATIONMODEL
NGUSE
r
EXISTINGSF
NEW FLOOR SF
PORCH
SF DECK SF
DEMO SF
STORIES
TOTAL NET SF
BATHROOM IF
REMODEL KITCHEN
IF
REMODELOTHR
IF
GARAGE ❑ ATTACHED
IF ❑ DETACHED
EXISING ❑❑ NO
FIRE SPRINKLERSNO
EICHLER 0 NO SECOND
STORY ADDITION [3 YE
DWELLING
UNITS #
SECOND DWELLING ❑YES ❑ ATTACHED ❑DETACHED. I OTHER
UNIT ADDITON: ❑ NO IF
POOLS
❑ FIBERGLASS ❑ VINYL -LINED ❑ GUNITE ❑ PREFABRICATED
POOL - IF SPA - IF SPA ATTACHED 13 YES ❑ NO TOTAL - IF
Commercial orMulti-Family Buildings with Public Swimming Pools requires Department ofEnvironmental Heath approval
RECEIVED BY:
I
F
RE -ROOF
EXISTING ROOF TYPE: ❑ BUILT-UP ROOF ❑ ASPHALT SHINGLES[] WOOD SHAKES ❑
WOOD SHINGLES 1LE OTHER (SPECIFY)
REMOVE/REPLACE O
❑YES
IF NO
I # OF LAYERS
PLYWOOD ❑'h❑3/B' PLYWOOD
THICKNESS ❑ 5/r OTHER
TYPE:
❑OSB ❑ CDX OTHER
PITCH:L�
12
ROOF CLASS
A
PROPOSED ROOF TYPE: ❑BUILT-UP ROOF,XASPHALT SHINGLES ❑ WOOD SHAKES ❑ WOOD SHINGLES ❑ OTHER ��,,
*Provide a signed copy of the Cup rtino's Tear -Off Policy SF #o 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 is correct. I have read the Description of Work and verify it is accurate. I agree
to comply with all apCordinances and state laws relatin to building construction. I authorize representatives of Cupertino to
enter the above-identiperty o information Font ' ed on this application form
to be made available fc record. 2
Signature of ApplicanDate:
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