S 3164 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPH:R'I'INO BUIIAING-ELECT RICA]. I'E IT NO
BUILDING DIVISION APPLICAT'ION/PERMIT TING P OJECT IDENTIFIC 3164
BUILDING PROJECTIDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
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I OWNER'S NAME: t PH(INE: - CONTRACTOR'S IC NO:
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CON_SJTp�i'f �M1� ST J��LOSE �f /TL BUII,DINC PERMIT INFO
COST
Zi 5 �-•�•�3 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
117, /&(s/E:V ❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERNHp FEE
1 hereby affirm that I am licensed under provisions or Chapter 9 6anum nuing JOE DESCRIPTION
0 a'Z with Section V000)of Division 3oftbo Bwonesvfinl Note vsian.Codganiny license i. RESIDENTIAL:
1�-gg- in full formandeRect. PERMIT ISSUANCE
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