ApplicationD)P' 2,e)7q— to
APPLICATION FORM
Contnt>,ttlity Development Depailment
10300 Torre Avenue
Cupertino, CA 95014
CUPERTINO
(408) 777-3308 / Fax (408) 777-3333
planning@cupei:tino.org
I-tLtp://www.cupertitio.org/plannh-ig
Property Owner Phone (w) Phone (h)
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Street Address Fax Cell
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City, State, Zip Code 8-Mail
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Projec�ontact Person 1 Phone (w) Phone (h)
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Street Address Fax Cell
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City, State, Zip Code E-Mail
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r' o ect. ddress APN (s)
Brief Project Description
i certify that the foregoing stateatents are trite and correct to the best of my kno vledge. l i.tuderstartd that a antisiepresentatiori of atty
submitted data may invalidate au approval by the Director of Corttmntihj Development, Design Review Cominittee, Planning
Commission or City Ccancil of this application. I understand that the application may be uiithdrawu if my mithoized
representative or I is not present at the scheduled meeting(s) tuiless a zoritten request for postponement has been presented to the
applicable reviezn body. I have discussed this application with the Public Works Staff and I miderstand the public iiaprovement
regttiremeuts associated with this proposal. I tutderstand application fees are nonrefundable.
Apphcar is Signature D to
2 declare under penalhj of pet jury that lam the owner of said properhj or have Power of Attorney (attach copy) front said property
ozoner and that I consent to the above -described application and I mithorize City staff to visit tine site in order to take photographs,
slides arid/or videotape that may be shozott at a city meeting. I imderstand application fees are nourefttndable.
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Property Owner's Signature Print Property Owner's N' ze Date
Staff use oil-
Application accepted by� on 3 1�
Application type:
For Atretidments or Modifications, list the original permit:
Sheet 2 of 9
App2014--15.doc revised 717114