B-2017-0070 Application GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISI N
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
Cl1Pl;R"i'tNO (408)777-3228• FAX(408)77,7-3333•build ing(akuoertino.org misc
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Z—PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑I MISCELLANEOUS
PROJECT ADDRESS �a �APN# 15—(]I1` rJ
OWNER NAME �(C�VI � l j PHONE/el 1 /I EAII
STREET ADDRESS 6 _ / I ,STAIP(�` I �)Ll `oJS FAX
CONTACT NAMENi�&I \ _ r PHONT ( ��5_9 3� E-MAIL
STREET ADDRESS t U CITY,STATE,ZIP FAX
❑ OwNER ❑ OWNER-BUILDER ❑ OwNERAGENT. ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT El ENGINEER 11 DEVELOPER El TENANT
CONTRACTOR NAME � LICENSE I�[JM R LICENSE TS{PBUS.LIC# :7-'q:7-'q9-
COMPANY -
COMPANY NAMEc-;-r I 1/� 10 m�I n E-MAIL FAX
STREET ADDRESS J CITY,STATE,ZI ON
ARCHITECT/ENGINEER NAME LICENSE NUMBER I BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WIIALAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLERHOME? ❑NO
DESCRIPTION OF WORKp
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TOTAL VALUATION: RECEIVEI)B
By my signature below,I certify to each of the following: I am the property owner or authorized agent t e property owner' al£ I have rea
application and the infonnation I have provided is olTec. I have read the Desen tion of)A7ork and verify i Is acc o comply with all applicable local
ordinances and state laws-relating to bu' g c c' n. I a nze represen tives of Cupertino to enter the above identified pr perty for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED oFicE USE ON i
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EXPRESS
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MEPhfiscApp_2011.doc revised 06/21/11