S 2004 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPF,RTINO xun,Dlrva-ELecTRIcnI, P,yp TNO ^O O
]BUILDING DIVISION APPIACATION/PL
ERMIT PLUMBING-MECHANICAL t\J
pBUIUIING PROJECT IDENTIFICNOON
BUILDING ADDRESS' SANITARY NO. APPLICATION SUBMITTAL DATE
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OWNER'S NAME: Z��PHONE: CONTRACTOR'S NAMIi: LIC NO:
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CONTACT: PHONE, BUILDING PERMIT INFO
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LICENSED CONTRACTORS DECLARATION QTY 'ELECTRIC PERMIT FEE
I hereby ofnrm than 1 am licensed aver,umdahms of chapter v(commencing - JOB DESCRIPTION
0WaZ wimS¢tion]000)ofD'rvi.inn 3nfabe Businessand Professiow Code,andmy live n..is RESIDENTIAL:
FO� in full force and effect PERMIT ISSUANCIi
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1U ❑KITCHP.N REMOUEREMODELU License Class hie# APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-I[PH
M Dnlc - Canlrnctm
4 ARCHITECT'S DECLARATION El MULTI-UNIT ❑S'T'RUCTURAL
PANEIS
Z O y undemmnd my plum shell be used us public rcconts MODIFICATION
Oy„p UP TO 200 AMPS ❑TNT fPRIOR El CHIMNEY REPAIR
Tweaked Professional 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
OWNER BUILDER DECLARATION OVER1000AMPS El BATH REMODEIIREPAIR ❑DEM01.1'fiON
C 04 1 hereby from shot 1 vm ernnpl tram the Cantrackr'a Licence Law ter the
W 2 O y U following reason.(Sechum 9031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL El OTHER
W N which acct ires a perm n to conelmcn,alter,improve,demolish,or repair any structure 'r
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