BLD-2023-1978_ApplicationCONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • permitcenter@cupertino.org PERMIT #BLD,? �1
CUPERTINO I REV# DEF#
❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION 12 T.1, ❑ MEP ❑ RE -ROOF ❑ SWIMMING POOL/SPA
PROJECT ADDRESS n �/J^ ,� � �Z
(� S ✓t
APN ri
OWNER NAME PHONE
E-MAIL
STREET ADDRESS
CITY, STATE, ZIP
ONTRACTOR NAME ❑ OWNER -BUILDER COMPANY
NAME
LICENSE NUMBER
LICENSE TYPE
STREET ADDRESS
CITY, STATE, ZIP
Wo . 51 •10o
M L S
E-MAIL lPnONE BUS. LIC n
-- 5-b -0 2 3 5"-7
❑ ARCHITECT ❑ OWNER ❑ OWNER AGENT ❑ CONTRACTOR AGENT ENGINEER ❑ DEVELOPER ❑ TENANT
CONTACT NAME
E-MAIL
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTON
TOTAL VALUATION:
❑SINGLE-FAMILY/DUPLEX ULTI-FAMILY ❑ IIVDUSTTZIAL ❑COMMERCIAL
USE
TYPE
OCC
SQ.FT.
VALUATION ($)
EXISTING USE
EXISTING IF
NEW FLOOR IF
PORCH
IF DECK IF
DEMO IF
STORIES #
TOTAL NET IF
REMODEL
REMODEL KITCHEN
REMODEL OTHR
GARAGE ❑ ATTACHED
BATHROOM IF
IF
IF
IF ❑ DETACHED
EXISING .YES
EICHLER DYES
I
SECOND STORY ADDITION ES
[IFIRE SPRINKLERS NO
Jji NO
WN0
DWELLING
[:]YES []ATTACHED[] DETACHED OTHER
UNITS #
�SECONDDWELLING
UNIT ADDITON: ❑ NO S F
POOLS
❑ FIBERGLASS ❑ VINYL -LINED ❑ GUNITE ❑ PREFABRICATED
POOL - IF SPA - IF SPA ATTACHED ❑ YES ❑ NO TOTAL - SF
RECEIVED BY:
Commercial or Multi-FamiliBuildin4s with Public Surimmina Pools requires Department of Environmental Heath approval
RE -ROOF
EXISTING ROOF TYPE: ❑ BUILT-UP ROOF ❑ ASPHALT SHINGLES ❑ WOOD SHAKES ❑
WOOD SHINGLES ❑ TILE OTHER (SPECIFY)
REMOVE /REPLACE ❑ NO
TF NO
PLYWOOD ❑' z ❑ 3/8" PLYWOOD
TYPE:
PITCH:
ROOF CLASS
❑ YES
# OF LAYERS
THICKNESS ❑ 5/8" OTHER
❑OSB ❑ CDX OTHER
•12
A
PROPOSED ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES ❑ WOOD SHAKES ❑WOOD SHINGLES ❑ OTHER
*Provide a signed copy of the Cupertino's Tear -Off Policy SF ttof SQUARES
By my signature below I certify to each of the following: I am the property owner or authorized agent to act on the property owner'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 laws relating to building construction. I authorize representatives of Cupertino to
enter the above -identified property for inspect' n purposes. I cknowled e and authorize all informati�coained this application form
to be made available for public record.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED
*New SFD/Second Dwelling Units/Multifamily Dwellings: A Demolition permit is required prior to issuance of a building permit for all new construction.
*Commercial Buildings: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project.
*Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application.
*HOA-Provide a letter of approval from the Home Owner's Association
4f G13,,7Z BldgApp_201 7. doc revised 01101121