21291 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PERMIT NO.
Building Address: 21291
Dara one:
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(_ CITY OF CUPERTINOQBUILDING DIVISION 0 Sip 0
Contragorm sore: LIc.N. APPLICATION / PERMIT LL
:L 16 BUILDINGELECTRICALPLUMBING.MECIIAMCAI. CATEGORY CONTROL#
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QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: - PERMTISSUANCE ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
I hereby a
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APPLIANCES—RESIDENTIAL JOB DEQS-CeRS�B�TTO
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Date Contractor
DIICLA AT'CSN/ C 201-1000AMPS
UP TO 200AMPS
ARCHITCCPS DECLARATION
m0 O I understand my pisco stall be used u public rcmrda ' r OVER]000 AMPS SQ.FT.FLOOR AREA 5/SQ-FT.
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O Licensed Prdesslonal �.-� SIGNS ELECTRICAL
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OWNER-BUILDER DECLARAT SPECIALCERCUIT/MLSC
1.," 4 1henbyalftrmthat l am exempt form the Contra Ji