MX-M1100_20160719_191934CUPERTINO
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CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • build ina(Dcupertino.ora �b K 1166E
❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / Ti ❑ REVISION / DEFERRED ORIGINAL PERMIT #
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PROJECT ADDRESS .L2-
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OWNERNAME
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PHONE Itu
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STREETADDRESS
CITY, STATE, ZIP
FAX
CONTACT NAME
PHONE
E-MAIL
STREET ADDRESS
CITY, STATE, ZIP
FAX
EI OWNER ❑ OWNRR-BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME 1
LICHNSENUMBER �/t
LICHNSETYPE
BUS. LICE
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COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECT/ENOINEER NAME h
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D�K�
LICENSE NUMBER
BUS. LIC# V 6
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COMPANYNAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
MISTING USE
PROPOSED USE
CONSTR. TYPE
# STORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION ($)
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
BATHROOM KAGIIEN OTHER
REMODELAREA REMODEL AREA REMODELAREA
PORCH AREA DECK AREA TOTAL DECKIPORCH AREA
GARAGEAREA: ❑DETACH
ATTACH
#DWELLING UNITS:
IS A SECOND UNIT El YES
SECONDSTORY I]YES
BEING ADDED? ENO
ADDITION? ENO
PRE -APPLICATION AYES B' YES, PROVIDE COPY OF
IS THE BLDG AN AYES
RE EIVED BY
T "AL
VALUATION:
PLANNINGAPPL# ENO PLANNWGAPPROVALLEITER
EICHLER HOME? ENO
I
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act oil the property owner's behalf. I have read this
application and the information I have provided 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 b ilding snr don. I au[hotize Icpre&ontatives of Cupertino to enter the above -identified In for inspection purposes.
Signature of ApplicanT/Agent: Date: �-
SUPPLEMENTAL INFORMATION REQUIRED
PLAN CHECK- TYPE°
ROUTING SLIP
❑ OVER THE COUNTER'.'
❑ BUILDING PLAN REVIF.N
New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
❑ EXPRESS
❑ PLANNING PLAN REVIEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD
❑ PUBLIC -WORKS
form if any Hazardous Materials are being used as part of this project.
I-] LARGE _
❑ FIRE DEPT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
❑ MAJOR
❑ SANITARY sE\vsamsrlHCT
submittal of Build iig Permit application.
❑ ENVIRONMENTAL H F.ALTH
B1dgApp201 L doc revised 06121111