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�L.I� T'9 F CE �"IFi� T'� F � l�� Y
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIA�
�����„���� 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408)777-3228 • building(a�cupertino.orq
COMPLETE A SEPARATE APPLICATION FOR EACH BUILDiNG:
PROJECT ADDRL-S�, � ��. �� �; � ���� � APN ft g DATE '�
�~ e� ���,� e�"�"�� �'..-�--✓"� � :�UPERTINC?, �A � � `
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RpE�,qC,ADDR SS r �,f �;,.���!' � ti CITY,^t7,�TAl'E,Z � , �
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ST E�S,ADDRESS ,,� CIT,Y, STATG,7_IP . � r� �"� s*� t
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MAIL CERTIFICATE TO: Please allow u to 10 business da s for delive
CONl'ACT NAMG. 6 �� „��J��� X PHONE� �,+�� � � �� E-MAIL ����e��.���''"t ����/j�{ � ��
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STREET ADDRESS i � / �^'T� � � CI'CY,ti S ATE,Z[P
� � �x °'� . �� ��'�� __``� `�� � ��� ��`" �,.��,��
LIST ALL BUILDING PERMITS ISSUED FOR PROJECT:
PERMIT NUMB�R DATE FINALED INSPECTOR SCOPE
1 �� �`���.� �"��€ � � , (� �-.-"�.,- �..��� s� .
2 4 .
3
4
- OFFICE USE O1�1LY-
SPECIAL STIPULATIONS OR CONDITIONS: CHECKLIST:
Permit signed off in system?
No other permits open or expired in system?
Verification of payment for certification7
CofOApplicatian.docrevised 06/01/20