NO PERMIT NUMBER *Clt.�
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Cupertino
CHANGE OF ADDRESS
REQUEST FORM
NAivIE (please print): ual, a
TELEPHONE NUMBER: (�PA1 g1 a-�!el e
APN:
EXISTING ADDRESS: ? /t /`w�EiNo
NEW ADDRESS REQASTED:
�D�' firo �S � irt/ �i9GK
Requests for reassignment of addresses will be approved if consistent with the following criteria:
• . 1. The change of address will not create confusion.
2. Only the last digit will be considered.
3. The odd/even addressing system will be maintained.
4. The change in address will not result in a public safety problem.
5. Proof of ownership and picture identification is required.
The fee for change of address is $126.00 The fee is due with this request form and will not be
refunded if request is denied.
The direct costs associated with a request to change address will be borne by ithe applicant.
Approximate review time is fifteen(15) days. If change of address is granted, the new address will
be in effect thirty days following.
igna e
Date
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1940A 14 /