5443 APPLICANT TO FELL IN,INFORMATION WITHIN.13ED LINES -"USE BALL POINT PEN ONLY
'
BUILDING PROJECT lDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT'-
. a...Tax - ._ �11 '...
nooREaa � 54 4 3
�� :.. E ' BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S .. '.:ry .' - -' -� - - _ - _.- _ --- PLAN CHECK VALIDATION"
_ QTY. ELECTRIC PERMIT - `FEE PAID
o �Tf ar PHONE' PAID'
C M RAc ORS - OUTLETS-SWITCHES-RECEP- 5.00/1.00 Q
L./ ilC.xo. a3 �'Q70 LIGHTING FIXTURES 5.00/1.00
b RE5APR 17 1984
C RACTOR's PPLIANCES-RESIDENTIAL, , Q
(g5 4.00 ,
T " -Ni 7.r PANELS 5.00 E
ARCHITECT PLA E .C.NO.
• on .. SIGNS. . • 6.00 ..
ENGINEER
• LIC.NOJ ' SIGNS TRANS:' 3.00
ADR. R ExG. r PERMIT VALIDATION"
'ADHESS -SPECIAL CIRCUIT 5.00 4O
zlv EMP.METER,OR POLE INS. 15.00
APPLICANT'$ ('
AooREss MOTORS SEE FEE SCH. �( I Q -
SERVICE CHANGE 10.00 (/ O
o¢2 ,
r-o o LICENSED CONTRACTORS DECLARATION R D(�/,.''!J ' ( cT. .0.� ��/' .,
r <i c I hereby affirm that 1 am licensed under provisions of Chapter 9 /N S_ V ( ISSUANCE DATE '
a (commencing with Sec[iom7000)of Division 3 of the Business and _ - B ELE T. PLG. MECH.
F N i Professions Co a`A my license is in full fin f ❑,
y o m- License lass Lie in
J -
9.Z f w Date Contractor / N A �. r C.C CT S'3G' �'�
L W
a m 2 _5 - ', BU DING RMIT
¢ ¢ n 4 OWNER-BUILDER DECLARATION - INFORM AT
row.
;LL'N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD "
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