25143 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO . munmr.'RF.Rc^rR AL PERMITNO.
I BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECTIDRNITFICYI]ON 25143
/-'4A, B ILDING ADDRESS: SANITARY NO. APPLICATION SSUBMITTAL.DA'lli
UNIT Is LOT
I; .VNERSNAME: PHONE: CONTRACTOR'S NAME LIC NO. 111 4t7
NIC ^CONI'ROLp
®A CHITIiCT/IiNGINEER: LIC NO:I DRESS: El
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BIILDING PERMIIIT INFO
BLDG ELECT PLUMB ML'❑11
C
PERMITISSUANCE r� �IQ(t
LICENSED17—
CON'IRACfOR;S DECLARATION APPLIANCES-RESIDENTt
I hereby ffimr that lam licensed under fautp 9(commencin th ^ JOB DES+CRwIPT'ION.,
❑CZ Ya pmvieofemn per Bis
X00 Setiorm=it ff Division Jof the Business and Profcuions Code.and mylittveuin PANELS
y�l�F�. fullmmeanJ effect. `
6F Z W -cense Clans Lic.N OPT A
serDate Contractor - PS FTp� R��
i-yZz ARCHITECTS DECLARATION 1000AMP5 / IcSI ) IN
$/S FT.
Z O m— I understand my plans shall be used as public raorda. //f\sl
cN ItlL Fw SIGNS HLECTRIJAL
Q j