B-2016-131602/04/2016 THU 11727 FAX FaDt Water Heater
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CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 4 Map
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 2 l
(408) 777-3228 - FAX (408) 777-3333 • building0cucertino.Dra
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❑ OWNER ❑ OWNER-OUII.DPR 13 OWNER AGENT CONTRACIVK ❑ CONTRACTOR AOENT ❑ ARCHITECT ❑ ENOINOER 0 DEVELOPER ❑ TGNANT
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nCSCRIPTION OF WORK
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EXISTING USE
PROPOSED USE CONSTR.
TYPE
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USE
TYPE
OCC.
SQ.FT.
VALUATION (3)
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NEW FLOOh
DEMO
TOTAL
AREA
AREA
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NET AREA
BATHROOM
KITCHEN
OTHER
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PORCH AREA
DECK AREA
TOTAL DOCK/PORCLI ARE
GARAGE ARTA: DETACH
ATI ACH
N DWELLING UNITS:
IS A SECOND UNIT VRB
SECOND STORY[TYP,9
BEING ADDED? C3 NO
ADDITION? ❑NO
PRE -APPLICATION ❑ YF.S IF YES. rROVIDE COPY OF
N PLANNF40 APPROVAL LFTTTIR
IS THE BLDG AN Q YES ly
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TOTAL VAI,U TSO
PLANNING APPL ❑NO
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By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. 1 have read this
application and the information I have provided is correct. I have read the Description of Work and vertfy it is accurate. I agree to comply with all applicable local
ordinances and slate laws rotating to bu' ding constructi�on.^I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: aM/8'V 1 Date:
SUPPLEMENTAL INFORMATION REQUIRED
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_ New SPD or Multifamily dwellings; Apply for demolition permit for
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existing building(s). Demolition permit is rCquir¢d prior to issuance of buildingyt
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permit fur new building.
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_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
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Form if any Hazardous Materials are being used as part of this project.
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_ Copy of Planning Approval Letter or Meering with Planning prior to
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submittal of Building Permit application.
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&VIttONK1ENTAL HEAthH .
BidgApp 2011.doc revised 06121111