S0439 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECI RICAL PFQRRMH No.
BUILDING DIVISION APPLICATIONXERMIT PLUMBING-MECHANICAL S F39
BUILDING PROJECT IDENTIFICATIONBUILDING ADDRESS: SANITARY NO. APPLICATIO
OWNER'S NAME: PHONE: CONTRACTORS NAME: LIC NO: NIC CONTROL#
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ARCHITECT/ENGINEER. LIC NO: ADDR S W ([ ❑ &QO
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CONTACT: PHONE: 6UILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB h1ECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 herebyaffmh that lam licensedunJcrpmvisionsnf Chap¢t9(enmmeacing _ JOB DESCRIPTION
OWZ with Section Jl%%p of Division Busineu unJ Prnfesions Cude.and mylicenwic RESIDENTIAL'
LLl O p PERMIT ISSUANCE
LLIF in full force and effect. ❑SFDW'L El KITCHEN REMODEL
QUU I,icenm Class [,it. APPLIANCES-R RESIDENT IAI, El ADDITION L1 PLUMBING RE-PIPE
FZW Dam Centimeter,
w¢L ❑SluLTl-UNIT ❑STRUCIVRAL
ARCHITECTS DECLARATION
F-p m PANELS MODIFICATION
O Z,4Z IunJcmd ln
anY Plans shud
all he xas public recnNs UPT0200AMPg
❑INTERIOR [I CHIMNEY REPAIR
=F,4 Licensed Professional 201-1000AMPS - IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BATH REh10DEFIREPAIR I:MOLITION
W W 1 herch mffrm Ihnt I am exn),u fount Ibe Contractor's License Low for the
k O c.U following reason.(Section 011,11 5,Rnsinc,s call Is f.•...is Calc:Any city or county SIGNS ELECTRICAL []OTHER
In 3"m which requires a permit m construct,alter,improvew
,demolish,or repair any scmre
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