29473 APPLICANTTO FILL IWINFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY "
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECDANICAL' n9 /I73
BUILDING PROJECT IDENTIFICATION L �{
BUILDING ADDfR17SS[� - SANITARY NO. APPLICATION SUBMITTAL DAH
OWNER" AME �A NE: CONI' CI'Ok'SN LIC NO:
litiv �ll+ NIC CONI'kOLp
RCHITECTAENGINEER: LIC NO: ADDRESS: ❑ -
CONTACT'. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) _ BLDC, ELECT PLUMB MECH
❑ ❑ ❑
LIC ENSEDCONTRACTOr'S DECLAkf QTY ELECTRIC PERMIT FEE .
I Hereby oder Inas 1 am licensed ander provisions of Chap mChapter 9 fenmmdng _.. . JOB DESCRIPTION
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o, with Section of Division 3 ofthe Business and Professions Code.and my license is X00 falce PERMIT ISSUANCE RE FDWI. TIAL:
F�UF, Licca forl.,s crtccf ❑SFDWI. ❑KITCHEN REMODEL
GUU License Class• Conor
hQL Dae - Commcmr APPLIANCES-R13SIDENTIAL ❑ADDITION El PLUMBING REPIPE
Fan ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
ZpyZ Imade...ndmy plan—haP be used aspshheorcoNs MODIFICATION
UP702MAMPS [I INTERIOR ❑CHIMNEY REPAIR
a 4taj Licensed Professional 201-I000AMPS IMPROVEMENT
C OWNER-BUILDER DECLARATION OVEkIf1110Ah1PS ,BATH REMODIi1JREPAIR �DF,MOLITION
Q 1 hereby afrinn that I am exempt from the Contractors License Law for the
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following reason.(Smtion]onstru Business and Professions Crude:Any city art county SIGNS ELECTRICAL ❑OTHER
W 3 w which requires a permit to enaarue,ane,improve,denudisM1,or repair any maward
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