B-2016-1190 Permit ApplicationCONSTRUCTION PERMIT APPLICATION �: �I6_ l f 190
COMPUNI f DEVELOPIVENT DEPARTIOENT BUILDING DIVISION VV
10300TORRE AVENUE • CUPERTINO, CA 95014-3255 MEMO
CUPERTIDiO• (408) 777-3228 - FAX (408) 777-3333 buildino(dcuuertino.oro
❑ NEW CONST2UCTION El ADDITION i,LTEg..4TIONl Ti ❑ REVISION/DEFERRED OlGOINar PE,-LI,tST;
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❑MZ-R. E.OWK-R-Btn.DER. ❑owmMZAGENT K1con.?Ltr,DR ❑cDMER-kCToaAsENFT ❑ A.RC=_CT ❑.NGa-eR ❑ D'ev_LO?aa ❑-Ntiz
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USE TYPE OCC. SQ.ZT. I VALUAnON(S)
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By my signature below, I certify to each of the fellowins: I am the grope q owner or authoriz_ went to act t ePopty owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of WDTk and verify ovate, I 2-Fee to comply with all applicable local
oreirences and state laws relatiDg to b gilding co aruction. I authorize represen-rives of Cupertino to enter the above-identi red pro/gory for inspection purposes.
Signature of-' pplicanvAgent: Date:
SLTPLEbibhrTAL TNFORbL - eQUIRED
NewSFD or'`Cultif�mi!y d\iyep�n p_pply for d..nolit,on no 'Cr
eXisting build:ne s it Is *ee�!'r ed goer to lsc
{) pert u ice of bL let
L�.Dv.c r ai,�\7 -
nv a r1= Gor,�rn� -�
..rie-rol?tion
per rit for new building.
Commercial Bldes. Provide a completed H=dOus Materials Disclosure
i� a�=me.RD•� � ��
Pu_�c„ o �c� � --
a"or-? ?f any Hazaz does Materials are being used as r .rr o, i,`,rs project
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Copy of Plamrrg App.oval Levier or >\heet ..- ;, ih PI-u-Lnmg prior to�`�
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Submittal Of Building Pe:n,t apDlieation.
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Bldg _pp_2011.doc revised 06/21/11