21291 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PERMIT NO.
Building Address: 21291
Dara one:
A
(_ CITY OF CUPERTINOQBUILDING DIVISION 0 Sip 0
Contragorm sore: LIc.N. APPLICATION / PERMIT LL
:L 16 BUILDINGELECTRICALPLUMBING.MECIIAMCAI. CATEGORY CONTROL#
A lerrllf d F glneer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: - PERMTISSUANCE ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
I hereby a
erebyehallam licensed eoneof
r9(com
APPLIANCES—RESIDENTIAL JOB DEQS-CeRS�B�TTO
N
Ingwith ..7000)of elon3.ftheBusissandPorfenionsCode and my t
Ecenxitinfull( deffect PANES
License Z. t.1 !4 2'�1,0 U
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.
�p
O Licensed Prdesslonal �.-� SIGNS ELECTRICAL
a6 Fag+
OWNER-BUILDER DECLARAT SPECIALCERCUIT/MLSC
1.," 4 1henbyalftrmthat l am exempt form the Contra Ji