S 2984 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-HLE(TFRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PIsRMIT PLUMBING-MECHANICAL
BUILDING PRO i(.T IDENTIFICATION S 2984
BU1LDI"DDRESS: f SANITARY NO. APPLICATION SUBMI'FI'AL DATE
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CONTACT: PHONE
BUILDING PERMIT INFO
Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE JOB DESCRIPTION
I herehy i firm that I am licenud under provisions of Chapter 9lamar ncing
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JJJ,...II OWNER-IIUII.DI:R DECLARATION OVER IAOAMPS ❑BATH REMODEVREPAIR 0DEMOLITION
1 hereby whom that I am exempt from Me Commcmr'n Limane law for the,
�y(O y U following reason(Section]031.5.atoinex,and 1•rofin,was Cale:Any city of county SIGNS ELECTRICAL it
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W 3 LL y which reences a permit to construct,alter,improve,danalish,(ir repair any swdure
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