08090095Con9odq.
CUPEKrINO
CITY OF CUPERTINO
REVISION/DEFERRED
PERMIT APPLICATION FORM
APN #
3 1
Date:
C. V,
1/0
Original Permit #:
a o z- b l
Building Address:
.21-7(l
Mailing Address (if different from building address):
Owner's Name:
Phone #:
Contractor:
Phone:
/1 ( (`� �F
Fax:
Contractor License #:
Cupertino Business License #:
Contact:
Phone: G�d� (I - -3 oo
Rao J A)
Fax: `'�v% Z z o
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Residential Commercial
Job Description: n
41�� 0065 S CT
Is the project in the Wildland- Urban Interface Fire Area? Yes ❑ No ❑
Type of Construction (Usage Class):
* Occupancy Type:
1-A, l -B ❑ II/IIIN-A ❑ II/III B, IV -HT, V-B ❑
Valuation (cost of project):
Project Size: Express Standard Large Major
Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it
to the application or if applicable, include in plan set & the sheet index.
Points Achieved:
For help, contact Build it Green at www.builditp-reen.org
Revised 9/ 15/08