00010025 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO nuu.nlnG.El.LcrxlGnL a0 I'IiNMI'I'NO,
BUILDING DIVISION APPLICATION/PERMIT 1'L11M111NG-MECHANICAL SOOOI
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OWNS :SNAME: PHONL: CON'FRAC'IDR:S NAME: LIC NO:
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CHITEC'I'/E EER: LIC NO: ADDRESS:
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CONTACT THONG /� BUILDING PEI2M1'I'INFO
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LICENSED CONTRACT'OR'S DECLARATION QTy. ELECTRIC PERMIT FEE JOB DESCRIPTION
I hcaby affirm that I am IiwneN under provisions of Crane,') toancing
O fEZ wire senuan nxxB nr Dtvkslon3nnbe Budnessaw Profexsianl Cod,andmy limns is RESIDENTIAI:
I'IiRMIT ISSl1ANCE
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QUU License Class Lick APPLIANCES-RESIIIENI'IAI, ❑ADUHFION ElPLUMBING RE.PIPE
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ARCHITLCTS DECLARATIONPANIU.S OhIULTI-UNIT ❑STRUCTURAI,
1" z I understand my plont,hall he used on public record% MODIFICATIONZ OOil 10200 AMPS ❑INTERIOR C]CHIMNEY REPAIROz. o
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OWNER-BUILDER DECLARATION OVER ITMOAMPS HATH RIih10DIi1J121:PA1R ❑DLh101.1'I'ION
1' Q I Turnery uMnn that 1 am exempt form the Comomme,License Law for the
aa 3a U following reams(Section]11315,Fanniess and I4nfessions Csxfe:Any city nr cnumY SIGNS L'LIiCfRICAL ❑(IIIIRR
,n which aquias a permit m construct,alcor,improve.demolish or repair any Immure
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