7092 AP,P ICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY-
PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION
BuILmNG />PPLICATION & PERMIT
ADDRESSIn PA
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 7092
-� ow EP's 3q PL AN CH ECK VA LIDATION
�1 " DTV. "d ` bE 'LE_CJTRIC'E MIT yy��,a�ry1_ "M FEE'`'
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PHONE +T' Yi N TA eV f4. :n`ry tAdy14 looks
C TRACTOfl5 ^•+u.
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00 PAID
\S�c 'Vs b .5C.NO. . LIGHTING FIXTURES 5.00/1.00
`- CONTRACTOR'S PPLIANCES-RESIDENTIAL 4,00 q� 15
1y f. ..
Y pLi J L t c*PHONE�j S'� PANELS 5.00 `/D(riiE'ov APPLICATION
I ARCHI ECT OR SIGNS. 6.00 PLAN CHECK FEE P.C.IN
ENGINEER' - lllly I)1 C!!(}2I iI11V!
uc.Nb. "53 SIGNS TRANS: 3.00 f
ADDRESS ENO' _ SPECIALCIRCUIT '5.00 PERMIT VALIDATION
ZIP, ' -EMP.METER OR POLE INS. 15.00
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS'
SERVICE CHANGE 10.00 . I g�
wo ♦ LICENSED CONTRACTORS DECLARATION -
<u 1 hereby affirm that 1 am licensed under pmvisimns of Chapter 9 IBSUAICE DATE
y< (commencing with Section 7000)of Division 3 at the Business and BLDG. ELECT. P G. MECH.
H yaz Professions Code�an�my license is in full iq',•q❑ cff cl, ❑ ❑ ❑
Z,o s. License Class L�7 E1_Lic.Number' "I G 3
O y L 0 Date 1-TS 5S j Contractor "
P m s'� BUILDING:t RMIT 9" •
w u OWNER-BUILDER DECLARATION �'Iltllr TION .:i4-;:.^
X3:3: w I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
w0 JI Law for the following reason,(Sec.7031:5,Business and Professions PERMIT.ISSUANCE 6.00 VALUATION S/FT.
Ew> F Code:Any city or county which requiresa permit to construct,alter, -
I[ al Q,° improve,demolish,or repair any structure,prior to its issuance,also ELEC.,CONTR. LIC.NO. ELEC.
o, requires the applicant lot such permit to file a signed statement Thal. TOTAL PERMIT TO
e atm he is licensed prusuunt to the provisions of the Contractors License
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