B-2017-0070 Request for ExtensionCITY OF
REQUEST FOR PERMIT EXTENSION
Please e-mail the completed form to
building@cupertino.org
CUP RTINO
❑ Under Plan Review Process (up to 90 days (s mo.) extension) �ssued
Permit (Up to 180 days (6 mo.) extension)
Building Address: Permit Number:
Owner Name: 13 y 069
Owner Address: // `-T q!�) A 16.r4 . Phone: �4 U ? - Zcjg - g(� 6 c)
CA /
Contact Name
E-mail Address: C'sb.,f� SGis r Phone: _I g - �1 - �� �b
Reason(s) (please be specific):
Signa
Date:
OF CUPERTINO USE ONLY)
Yes No
Approval: ❑ Expired Date: 3. o? 3
Fee: $
Revised 7/25/2017