11071 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
8� BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING 1 APPLICATION & PERMIT
nDORESBIo�^� .RRR'b I .N. 11071
l.� BUILDING —ELECTRICAL—PLUMBING—MECHANICAL
OWNER'a f' _ ,a' PLAN CHECK VALIDATION
NyAMyE� QTVC ' ELECTRICPERMIT FEE
1 1� C 1l PHONE
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
�A�E +
�f A11� � TI�IT ua No. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS '1 n I� ' APPLIANCES-RESIDENTIAL 4.00
AODRE J
PHONE PANELS - 10.00 DATE OF APPLICATION
RCNrtscT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
O
OR
ENGINEER
LIC.No. ISIGNS TRANS. 3.00
ADDRESS enc. SPECIAL CIRCUIT S.00 PERMIT VALIDATION
IIP TEMP.METER OR POLE INS. 20.00
AESNr's MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE, 20.00 ll� s / fie
Doo LICENSED CONTRACTORS DECLARATION 1�0 T
4 u u I,hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
y st vAi (commencing with Section 7000)of Division 3 Of the Business and BLDG. ELECT. PLG. MECH.
F,y z Professions Cod ryad n -1'cense is in full f 4 y��
Z o 0— Licca la's Lw.Nunil h y T�-.-� ❑ ❑ ❑ I`7-ll'I
D u t ° D_ale Contructo � C
-< a 2 -, BUILDING PERMIT
¢ ¢ < OWNER-BUILDER DECLARATION
X i;u INFORMATION
A.
; w m 1 hereby affirm that 1 am exempt from the Contractor's License MISC.— REFER TO ORD VALUATION
I� 0 < Law for the following reason.(See.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 $/FT.
W0 � Code:Any city orcounty which requiresa permit m construct,alter,
> ELEC.CONTE. LIC.N0.
ac ¢ ¢ 0 improve,demolish,or repair mry stnmfure,prior to its issuance,x150 ELEC. -
w0¢ requires the applicant for such permit to file,a Signed statement that TOTAL PERMIT.TO
$ he is licensed pursuant to the provisions of the Contractor's License I-
rii