09030206CITY OF
CUPERTINO
CITY OF CUPERTINO
REVISION/DEFERRED
PERMIT APPLICATION FORM
Oq (:)3 D,) -o1 (A
APN # ot 6 Lo o.
Date:
Original Permit #:
Building Address:
Mailing Address (if different from building address):
Owner's Name:
Phone #:
Q 0 b e- 1
909 -'2 -9 -S -
Contractor:
Phone:
6-ree0r,Y?ol ley
_
Fax:
Contractor License #: , 41 C ,
Cupertino Business License #:
Contact:
Phone:
6'rMC, I e- w
Fax:
Buildin ermit Info:
Bldg P4 Elect Plumb ❑ Mech ❑
Residential ❑ Commercial
Job Description: M0,14 i 1, + iip if
Is the project in the Wildland- Urban Interface Fire Area? Yes ❑ No ❑
Type of Construction (Usage Class):
* Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV -HT, V -B ❑43
42- 13
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.buildit reen.or
Revised 01/07/09
ell
/Y.
Peryt,
7
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RECEIVED
A! -IG 20 2010
BY.