30589 (2) APPLICANTTO FILL IN INFORMATION WITHIN hED LINES,-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING-ELECTRICAL. 'PERMITNO. as zw
BUILDING DIVISION APPLICATIONIPOEkIlITT PLUMBING-MECHANICAL �V(9
BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS: �� � SANITARY NO. APPLICATION SUBMITTAL DATE
76'3 GTD�
L"6
OWNEjiIS NAME: PHONIi: __ - CONTRACTOR'S NAME: LIC NO: .
O _,r —� e e NIC CONTROL N
2fill E NGINEER %-;r NO: ADDRESS y ❑
CONTTALT'. d i�-�oqM-]'2l- PHONE: BU
a BUILDING PERMIT INFO
SNf/o� � /k�„r�i 'V.�—w.,Z ❑ Consultant Fees Paid by Applicant(Initial) e ELE PLU� MECM
NY*P LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby allion'hot 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
yyZ�wz with Section 701RBofDivision 3afthe Businessand Professions Code,and my license is RESIDENTIAL,
F-0O full force and effect. PERMIT ISSUANCE �
ad— in s'� ❑SFDWL �N CITCHEN REMODEL
�FVZNUF`�. Loren.Cl LIC.N APPLIANCES-RESIDENTIAL DITION SLJ P�UMBING RE-PIPE
N6y hate Contnicmr -
ARCHTTECTSDEC TION ❑MULTI-UNET ❑STRUCTURAL
Oz Z H Z 1 understand my plans shall be used us p lic records PANELS MODIFICATION
',?"' Ill'TO 200 AMPS
.z0 Licensed Professional [I INTERIOR [:1 CHIMNEY REPAIR
OWNER-BUILDI?R DECLARATION 20LIOOpAMPS /IMPROVEMENT
�cs+"'� OVER IM)AMPS �/aTH REMODEVREPAIR DDEMOLITION
G LL 1 hereby affirm that 1 am exempt from the RATIO Contractor's License Low for the "[[]]
O V following reason.(Section 7071.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL OTHER
�f which requires a permit to conswa,alcor,improve,demolish,or repair any stmcmre .
prior to its issuance,also requires the applicant for such rental in file a signed statement SPECIAL CIRCUIT/MISC.
{ }
that he is licensed pursuant m the provisions of the Cmd.brs License Law(Chapter 9
ftCl a� (commencing with Section 7")of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE IN ST. COMMERCIAL:
d y e a that he is exempt therefrom and the basis for the alleged exemption.Any violation of ) [I NEW BLDG/ADDITION E]DEMOLITION
4X7 Ie
Section 701 IS by any applicant mi
for a Per 'zobjtt's Ne applicant to a civil penalty of POWER DEVICES ❑FOOD SERVICE
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