B-2017-0403 Extension RequestREQUEST FOR PERMIT EXTENSION
Please e-mail the completed form to
permitcenter@cupertino.org
❑ Under Plan Review Process Issued Permit
Building Address: y 5 �� LA �� ��g- Permit Number:?) tl _OL103
Owner Name: �-'U, '�/A�s� �� �� f 11 -7 MgDr
Owner Address: Phone% S�J ��� 6 TO t)R44r
Contact Name: 1
E-mail Address: iC'' be fl Phone:
Reason(s) (please be specific):
r - 60_�-O
fl � ; �t1S <o r/t -A -4, rs fa (� �� �f -� ��t
Signature: qi\ ' Date:
(CITY OF CUPERTINO USE ONLY)
Yes No
Approval: ❑ Expired Date: Fee: $ J.21. D O
v V•-
Revised 7/25/2017