B-2016-2423CUPERTINO
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❑ NEW CONSTRUCTION n ADDITION )kALTERATION / TI n REVISION / DEFERRED ORIGINAL PERMIT N
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building0cupertino.ora
PROTECT ADDRESS �.. / All/J 50 itY-�jQ )�% / �
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OWNERNAME �/D/VJ/[�AAQX,/_�' J (�
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PHONE 1 "'--;'1
E-MAIL
STREET ADDRESS �//J\t�J�Vy��L�/��
CITY, STATE, ZIP ' '_.e-a.q.-Q /1 FAXXy
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CONTACT NAME J�lOGL �-b �' 10ig-K (
PHONE 41y-,��� . r�
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STREET ADDRESS
CITY, STATE, ZIP
FAX
❑ OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑ CONTRACTORAGENT ❑ ARCHITECT ❑ LNGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAME
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LICENSENUMBER
LICENSE TYPE p
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BUS.LIC#
COMPANY NAME i p/n`
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FAX
STREET ADDRESS rD wl�jg �`tf�
CITY, STATE, ZIP 57V1 0b�l /4 150
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PHONE
ARCHITECT/ENGINEER1NAME K0 LtP" p ,"y
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LICENSENUMBER
BUS. LICN
COMPANY NAME 1nA
E-MAIL
FAX
STREET ADDRESSZ6,}Y� GfF�J(��ft-y(�
CITY, STATE, ZIP'- �,s-
PRONE
DESCRIPTION OF WORK/�J�, �yT�] W p f /) TA/`.rf J. h ,s/ i p �1 A A -le S e- pP 71 _ B a'3ASZ
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EXISTING USE
PROPOSED USE
WNSTR. TYPE
p STORIES
USE
TYPE
OCC.
SQ.FT.
VALUATIONEXIST($)
AREA
AREA
NEW FLOOR
.AREA
DEMO
AREA
NEC AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODELAREA ReMODELAREA
PORCHAREA DECKAREA TOTAL DECICTORCH AREA
GARAGEAREA: ❑DETACH
❑ATTACH
MDWHLLING ONns:
ISASECOND ONI'I' L]YES
SECONDSTORY OYES
BEINGADDED? ❑NO
ADDITION? []NO
PRE APPLICATION ❑YES IF YES, PROVIDE COPY OF
ISTHE BLDG AN ❑YES
--REC IVED BY
TOTAL
VALUATION:
PLANNINGAPPLN ❑NO PLANNING APPROVAL LETTER
Ir,ICI1LER HOME? El NO
lIp-Ti�tX,
QC\
By my signature below, I certify to each of the following: I am the properly owner or authorized agent to Acton tl property owner's behalf. I have Tread this
application and the information 1 have provide is co sect I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and slate laws relating to building c sln Lion. laorize rcpresenlalives of Cupertino to enter the above-i enli5ed prop�ertylfor has ec[ion proposes.
Signature of Applicant/Agenk _ Date:
SUPPLEMENTAL INFORMATION REQUIREDZ
PL.0 cHEcx TYrE`'
Rourinc SLIP
❑ OVER-THE-COUNTER
elUILDING PLANREWEW
New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
pennit for new building. -
❑ EXPRESS
IUKANNINGPLANREVIEW
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD
❑ PUBLIC woRxs
form if any Hazardous Materials are being used as part of this project.
❑ LARCC'
;G .FIRE DEPT
Copy of Planning Approval Letter or Meeting with Planning prior to
❑ mlA.loR
❑ SANITARY sDFhER DISTRICT,
submittal of Building Permit application.
-:-
❑ ENVIRONMENTAL HEALTH
m
B1dgApp_2011.doc revised 06121/11