B-2016-1486CUPERTINO
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building@cupertino.org
❑ NEW CONSTRUCTION I &DDITION
❑ ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT #
B
PROJECT ADD
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OWNER NA&MAIL
ST ET ADDRESS
CITY, STATE, ZIP
FAX
CONTACT NAME "—�
PHONE &MAIL425
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OWNER ❑ OWNER -BUILDER ❑ OWNERAGGNT ❑CONTRACTOR El CONTRACTOR AGENT I'FF.61' P.NGINEER ❑ DEVELOPER ❑ TENANT
CONTRACFORNAME
LICENSE NUMBER LICENSETYPE
BUS.LICU
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECT/EN. INEERNAA�I"
LICENSENUMBER
BUS. LICE
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COMPANY N Mp
&i- AIL
FAX
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DeSCk11Tr10N OF WORK ��
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BXISTINGUSE
PROPOSED USE
CONSTR. TYPE
ISTORTES
II
1
USE
TYPE
OCC.
SQ.FT.
VALUATION ($)
BXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
BATHROOM KITCHEN OTHER
REMODELARHA REMODEL AREA REMODEL AREA
1K `
Pen AREA DECK AREA
[00TIELLINGUSTIS:
TOTALDHCK/4 PORCH AREA
GARAGE AREA: DETACH
]q
tVA
y�
2 ACH
ISASECONDUNIT []YES
BEINGADDRID 0
SEC No$ BY ❑YES
ADDITION? i`I0
PRE -APPLICATION ❑YES IF, YES, PROVIDE COPY OF
ISTHEBLDGAN AYES
HIVED BYI
O'I�d. VALUATION:
PLANNWGAPPLN ENO PLANNING APPROVAL LETTER
EICHLER HOME? & NO
By my signature below, I certify to eact of the following: I inn the propel owner or authorized n act on the property owner's behalf. I have read this
application and the information I have rovided is correct. I have tl D eripti n of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and State laws relatin 6 b iIding construes . np sentati es of Cupertino to enter the above -identified property for spectiou purposes.
Signature ofApplicanUAgen� Date:
SUPPLEMENTAL INFORMATION REQUIRED
PLAN CHECKTYPE
ROD PING SLIP
'❑ OVER-THE-COUNTER
❑ BUILDING PLAN REVIEW
New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
permit fiar new building.
❑ EXPRESS
'❑ PLANNING PLAN REVIEW
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD
ElPUBLIC WORMS
form if any Hazardous Materials are being used as part of this project.
❑ LARGE
❑ FIRE DEFT
—Copy Of Planning Approval Letter of Meeting with Planning prior to
❑
❑
submittal of Building Permit application.
MAJOR
SANITARY SEWER DISTRICT
❑ ENVIRONMENTAL DEALTH
BldgApp 2011.doc revised 06121111