9392 APPLICANT TO FILL IN INFORMATIJPN WITHIN RED LINES - USE BALL POINT PEN ONLY
BUIL DING
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT PERMITNUMBER
9392
ADDRESS D3
UILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER
'S . -� PLAN CHECK VALIDATION
NAME QTY.' y�ELECTRIC PERMIT FEE
I40, G ,e P...t2,5;^-ao7
CONTRACTOR
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
L
BG7/'�C. LIC.ND. .g LIGHTING FIXTURES 10.00/1.00 59'
ADDRESS R's N$r[.n n'I✓2/fl. yep - APPLIANCES 4.00 00
ADDRESS // 7�
oZxarD /rC?WOU ,// PHOrvE -3#'-3 od PANELS 10.00 Qs DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,09 PLAN CHECK'FEE .C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
AR.OR ENG. SPECIAL CIRCUIT $,00 PEq - ION
ADDDDRESSSS
ZIP EMP.METER OLE INS. W.00 OCT 1, 11985
APPLICANT'S Q MOTORS p SEE FEES H. J
ADDRESS (�
e?6d 4vooal ocJI( nil SERV E CHANGE 4 2 .00 City of Cupertino
w o o LICENSED CONTRACTORS DGCLARATIO T P.POLE" 0.00 1,
< u v 1 hereby ffm.. that I am licensed under provisions of Chapter 9 Yd ISSUANCE DATE
y a u (commencing with Section 7000)of Division 3 of 1M1e Business and 'BLDG. L PLG. MECH.
F w i Professions Code and license is in full 1'urc ❑ ❑ ❑
z o m- License Class Lic.Number O
C)m�_0 are F/- Contractor
a Y f
a m w ¢ OWNER-BUILDER DECLARATION ) 0 ' !BUILDING,P.ERMIT y;;
U REFER TO ORD '+' s .LNFORIN_ T,1'O_N_;I .'T_' ,
w3 1 N I hereby affirm that I ani exempt from the Contractor's License MISC.-
n. 0 ¢ Law for the following reason.(Sec.7031.5,Business and Professions PERM ISSUAN _ 10.09 VALUATION
rN Code:Any city or county wltichrequiresa permit to construct,alter,
¢
<20 improve,demolish,or repair any structure,prior to its issuance,also ELEC. NTR. LIC-N0.!p ELEC.
u -0, requires the applicant for such permit to file a signed statement that 3 0 TOTAL /F PERMIT TO
w$ he is licensed pursuant to lite provisions of the Contractor's License - - ,} ,
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