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B-2017-0377 General applicationGENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION I 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 misc � �;��� (408) 777-3228 • FAX (408) 777-3333 • building(d)cupertino.org ® PLUMBING ❑ MECHANICAL ❑ ELECTRICAL ❑ MISCELLANEOUS C D S / t J F APN # �J C� —Z � © Y�% �j ®! EMAIL STREET ADD A-6 ck CIT STATE ZIP Y � vx_�l CA FAX CONTAC NAMja i \ P E -MAH. S _ . STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONT TOIeE LJCENSE NUMBER s �7LICENSE TYPE E_M COMP NAS \ I\J c - Jrn ,Y" (00 W) BUS. LIC #tj t /� F ' -- L%� i ST ET 01 lr� SO CITY, STl TE, ZIPi J 1C� (J�j O 1 $ `� ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ts. orDUPLEX I MULTI -FAMILY BUILDING: ❑ COMMERCIAL ✓ PROJECT IN WH.DLAND ElYES URBAN INTERFACE AREA ❑ NO PROJECT IN ❑ YES FLOOD ZONE ❑ NO IS THE BLDG AN ❑ YES EICHLER HOME? ❑ NO DESCRIPTION OF WORKQ. L 1. Ck ' r� vy\ �CASSL. `(A0 CV Qckw,� aca ` l + (Co y } \� TOTAL VALUATION: I By my signature below, I certify t 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 infonnatio hav provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relting authorize representatives of Cupertino to enter the above-iden tifie�prorty for inspection purposes. Signature of Applicant/Age t: Date: T( PLE E L INFORMATION REQUIRED OPFTCE USE ONLY © OVER-THE-COUNTER e. E 0 EXPRESS LJ U © STANDARD zV a ❑ LARGE © MAJOR MEPMiscApp_2011.doc revised 06121/11 ELI 1A