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CONSTRUCTION PERMIT APPLICATION ff\\u
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
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10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 �O
(408)777-3228 • FAX (408)777-3333•building(g)cugertino.org \
CUPERTINO
❑NEW CONSTRUCTION *❑1 ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS n 1 CJ0/1 v\�� APN e;� /-`ti -A r�)-0 CI
OWNERNAME PHONE � /f/ {� E-MAIL
STREET ADDRE:�/� » CITY, STATE,ZIP 1 I FAX
CONTACT NAME �I PHONtOS � T -244/ E-MAIL
STREET ADDRESS t T\/ 1 r CITY,STATE, ZI�q 1 T��� P FAX
❑ OWNER ❑ OU 1'NER-BUn-DER l❑ OWNER AGENT ❑ CO1,r R.ACTOR ❑CONTRACTOR AGENT ❑ C CT ❑EE.� INEER ❑ DEVELOPER ❑ TENANT
CON i RACTOR NAME LICENSE NUMBER LICENSE 'PE V BUS.LIC H
COMPANY NAME E-MAIL F
STREET ADDRESS CITY,STAT ZIP P O
ARCHITECT/ENGINEER NAME LICENSE N MBER BUS.LIC 4
COMPANY NAME FAX
i
STREET ADDRESS ITY, TATE,ZIP Jr PHONE
DESCRIPTION OF WORK / O
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C o Ve e o v-oCA SnAd
5Ir � k
EXISTING USE POSED USE CONSTR.TYPE k STORIES
USE TYPE OCC. SQ.FT. VALUATION(S)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PO$L}I A$EA DECK AT11
TOTAL DECK/PORCH AREA GAR4GE AREA: DETACH
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J[O ❑ATTACH
*DWELLING UNITS: A SECONDUNIT ❑YES SECOND STORY ❑YES
EING ADDED? E3 NO ADDITION? ❑NO
PRE-APPLICATION []YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑IBS REGEIVEID B�''� y TOT 6AT10N;�,r�
PLANNING APPL9 ❑NO PLANNING APPROVAL LETTER EICHLER HOME? []NO -�,. - t � • J1 U"
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. I have read this
application and the information I haveprovided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating t ing constructio thorize representatives of Cupertino to enter the ab ov -iidentifiieed�property for inspection purposes.
Signature of Applicant/Agent: � Date:
SUPPLEMENTAL INFORMATION REQUIRED = j P 'cicTCTrPE,sw- _ _ �RovTTnc sLIP;' t'':
New SFD or Multifamily dwellings: Apply for demolition permit for
-1]� OVER THl'rCOUNTER � � ❑ BUII,DI?\G PL.4N'RE«W��
existing building(s). Demolition permit is required prior to issuance of building '• k�+�YSF qty
permit for new building. - T XPI2ESS fl PLAp�TNG PLAT RI MTV-
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l a�sffa -a 4 S % sysy .'"'�' ,' 8 '`~'`}.ik €4 €*"� Y s°-5 n.
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ME
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form if any Hazardous Materials are being used as part of this project.
_Copy of Planning Approval Letter or Meeting with Planning prior to
❑ 1�TAJOR � fl SANITARY SEP1'SRDTSTRICT,� �
submittal of Building Permit application. fx tbIfr rs� x rK _.__4
B1dgApp_2011.doc i-evised 06/21/11