28043 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOPERMIT No.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 28043
BUILDING PROJECT IDENTIFICATION y t:f.,S;'d.s`
BUILDING ADDRESS:'a7 SANITARY NO. APPLICATION SUBMITTAL TE
AL DA
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OW RCNA a. E: CONTRACTOR'S NAME: LIC NO: ` �•
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RCHITECT/ENGINEER: (_ LIC NO: ADDRESS: ❑
CONTACT: PHONE: ,.css5 :Matwzt.>✓N sv P Qss;a: maw „r�"fy6 w"G4P:d", .BUILDING�PFEE NRNUTININFOs;int.
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pLDG ELECT' PLUMB MECH
PERMIT ISSUANCE IR(1yv ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIALJOB DESCRIPf1ON
PCm
Z I harbyaffirthat l an licensed under provisions ofChapter9(commencing with
?00 Section 70007 of Division 3afthc Businesxadd Professions Cade.end my liceme iso. PANELS
5UL Licensfull e
Cl.,-effect. MD
:Zyl Li<enx ClLic.X UP TO 200 AMPS P1/ �a
,<N Dae Comm, 201-IOW AMPS
V' S0.FT.FLOOR AREA $/SQ.PT.
Z ARCHITECTS DECLARATION OVER 1000 AMPS
Dy
1 understand my Plans shall be used as Public records.
F uO
nl SIGNS ELECTRICAL
LEJ Licensed Professional
y d'< OWNER-BUILDER DECLARATION SPECLV.CIRCUEUMISC.
7A, 1 hereby affirm that 1 sat exempt from the Contractors License Law for the
O N following reason(Sectiod7031.5,Business and Professions Code:Any city m county, TEM.METER OR POLE INST.
which requires a pemuconstruct,t to nstru ,alter,improve,demolish,or ropyan
, y stmeW.
�yv'IN2 pnorm its issuance,also.,or.meapplicantforsuch permit to file.signadsutamerrt POWER DEVICES
'<0 Lew(Chaprer
SWIMMING ELECTRIC VALUATION9(ommencing with Section 700)ofDivisio3 ofNe Businessand iseaioucode)
yr^y or that he is exempt therefrom and to basis fmthe misted exemption.Any violation of ^ LYo
=