13050141 l
CONSTRUCTION PERMIT APPLICATION
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COMMUNITY DEVELOPMENT DEPARTMENT a BUILDING DIVISION
103003 TORRE.AVENUE a CUPERTINO,CA 95014-3255 °,
(4Q8)777-3228 FAX(408)777-3333•building cupertino.org
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❑NEW CONSTRUCTION � ADDITION XAI, ATION 1 TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS „:, r 5 APN# q
C5 !f$a8P.."Gx- 1' �l � Z�', � 50
OWNER NA r P �� 6 EMAIL
STREET'ADDRESS CITY, STATE,ZIP FAX
CONTACT NAME PHONE MASL
STRE�TADD s'. ” e..,y S"Tti SA.f STATE,
A ,ZI �} FAQ % fCes;�
❑OWNER ❑ OWNER-BUILDER ❑ OWNER A ONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME $ AI ENSE NUMBER LICENSE TYPE SUS.LIC#
Cl
eOMPANYNAME t l,tt . E-MAIL
MS• t FAX
Y +cG. �CcAd Vf��,C1�GD^I�tJ'ikt"+*"a C�C M
STREET ADDRESS ,r /. CITY,STATE ZI d�d Q C�`p PIiO 4 a �'
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ARCHITECTIENGINEER.NNAMME ` ' •J J LICENSE NUMBER BUS.LIC#
COMPANY NAME �i /' E-MAIL FAX
STREET ADDRESS. g� (� y CITY,STATE,Z A i PHONE
DESCRIPTION OF WORK rs �� �/ 4 (r tt ;cC Ri �j�'+�e✓ Q (�
5 r- 6r / J
EmSTING USE PROPOSED USE CONSTR TYPE #STORIES
USE TYPE OCC. SQ.FT. VALUATION($).
EXISTGNEW FLOOR DEMO OTAL
AREA ..AREA _ AREA
i�5 NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODI L AREA REMODEL AREA
PORCH AREA ' ..DECK AREA TOTAL DECIUPORCH AREA GARAGE AREA: DETACH
. D ATTACH
#DWELLINGUNrrS:•- ISASECONDUNIT DYES
SECOND STORY DYES
BEIiVGADDED? ANO ADDITION? ®NO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF. IS THE BLDG AN ❑YES 3tEBI TOTAL VALUATION:
PLANNING APPL#, ❑NO PLANNING.APPROVAL LETTER EICHLERHOME? 6k�V-
By my signature below,I certify to each of the following: I am the property owner or authorize agent to ac e propertyowner'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 Iaws relating to building construction. I auth epresentatives of Cupertino to enter the above-id tified p operty for inspection purposes.
Signature of Applicant/Agent: Date:
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SUPPLEMENTAL INF{)RMATI N REQUIRED w
New SFD or Multifamily dwellings: Apply for demolition permit fort �� �� IiLnv � fz��
t .�o�R- c�Su�cJwR�a�
existing building(s):..Demolition permit is required prior to issuance of buildma � ��t r qty ' �'�� g
permiifor new building. EaYR7 sS a ��� P PL s�
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosures
form if any Hazardous Materials are being used as part of this project. ��� � �� � � .
_Copy of Planning Approval Letter or Meeting with Planning prior toIM �ItYE � t �
submittal of Building Permit application. � Y � ;`�t
B1dgApp 2011.doc revised 0612111-1