18832 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATIONPERMIT NUMBER
BUILDING APPLICATION & PERMIT ,
ADOREss 18832
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL Q-
OWNExe4tzk_�,
PLAN CHECK VALIDATION
NAME DTV. ELECTRIC PERMIT FEE
'vHory
NAMEys OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
f •uc.vD LIGHTING FIXTURES 10.00/1.00
CON
DovTRAcions - APPLIANCES-RESIDENTIAL 4.00
ADDRESS
.PHONE?; 7 PANELS 10.00 DATE OF APPLILAiION
ogcmTEc - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
' LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP EMP, METER OR POLE INS. 20.00
AORES5
ADORES MOTORS SEE FEE SCH.
SERVICE CHANGE - 20.00
w02 LICENSED CONTRACTORS DECLARATION -
is w I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 oC the Business and
ti< H - BLDG. ELECT. PLG. MECH.
r m Z -icer S io la s • �uS4 uQgly license is in full forpyplyj]ig12� ❑ ❑ ❑
or Date Contractor-
c,
ontractor '
Lu
BUILDING PERMIT
le w u OWNER-BUUAER DECLARATION INFORMATION
X3:
;LL H I hereby affirm that I am.exempt from the Contractor's License MI C.- REFER TO ORD
u Oj