application form dir-2019-02.pdfAPPLICATION FORM
Community Development Department
10300 Torre Avenue
Cupertino, CA 95014
CUPERTINO
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(408) 777-3308 / Fax (408) 777-3333
planning@cupertino.org
http://www.cupertino.org/plaiuiing
Property Owner Phone (w) Phone (h)
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Street ddress Fax Cell
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City, State, Zip Code E -Mail
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Project Contact Person Phone (w) Phone (h)
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Street Addressn Fax Cell
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Project Address / APN(s)
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Brief Project Description
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1 certify that the foregoing statements are true and correct to the best of uty knoruledge. 1 rrttderstand tlrat a misrepresentation of ratty
submitted data may invalidate an approval by the Director of Commuunihj Development, Design Review Committee, Planning
Commission or Cihj Council of this application. I understand that the application may be withdrawn if lily authorized
representative or 1 is not present at the scheduled meeting(s) unless a written request for postponement has been presented to the
applicable review body. I have discussed this application with the Public Works staff and I understand the public improvement
requirements associated eoith this proposal. I understmrd application fees are nonrefundable.
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Applic is Signature Date
1 declare under penalhj of perjunj that I am the owner of said properhj or have Power of Attorney (attach copy) from said property
owner and that I consent to the above-described application and 1 authorize Cihj staff to visit the site in order to take photographs,
slides and/or videotape that may be shown at a cihj meeting. I understand application fees are nonreftutdable.
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Proper Owner's Signature Print ro erty Owner's Name Date
Staff use onhL
Application accepted by ff on '1 9
Application type: 19V"4'is ► -Y, ri"4
ForAmendments or Modifications, list the original permit:
Sheet 2 of 9
A1ip2014-15.doc rez iced 717/14