BLD-2019-01274 Request for Permit ExtensionREQUEST FOR PERMIT EXTENSION
Please e-mail the completed form to
building@cupertino.org
❑ Under Plan Review Process (Up to 90 days (s mo.) extension)
Building Address: I
Owner Name: / V,Nk
Owner Address:
Contact Name:
Issued Permit (Up to 180 days (6 mo.) extension)
Ir" C_�- Permit Number:` ^ 2 D-01 2
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E-mail Address: Cjyc& ZJP-6�6) f^c-%'^d ,Oh"Phone: 2Sb—Sa('&
Reason(s) (please be specific): Orl 1 t A c-- V "a �- ` Y ml
Signature:
Date: L---)/y7L," >-
(CITY OF CUPERTINO USE ONLY)
Yes No
Approval: ?� ❑ Expired Date:
Fee: $ k Z k % O'�:4
Z 1 2-1 r 2zR ised 7/25/2017