5806 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —' USE BALL POINT PEN ONLY
' BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
mJrmNG APPLICATION & PERMIT 5806
a00n a5'•
_ ILDING ELECTRICAL—PLUMBING—MECHANICAL .
NER'Sa •;'!'4» PLAN CHECK VALIDATION
1 NAME ' ah n , M'. Y
I' !
DTV. ELECTRIC PERMIT FEE
NpMERac7oR's - - yUTLETS-SWITCHES-RECEP 5.00/1.00
t ) q
• L.C.No. /tSJ LIGHTING FIXTURES 5.00/1.00
nooeess To a - PPLIANCES-RESIDENTIAL 4.00 '
ONE PANELS 5.00 i, DATE OF APPLICATION
ARA
RCHITECT SIGNS B:Op PLAN CHECK FEE P.C.NO.
ENGINEEf1
' L.C.No. SIGNS TRANS. 3.00
ADDREOR SS ENG. SPECIALCIRCUIT '5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
gPPLICANT'S r+
ADDRESS MOTORS - SEE FEE SEH. J
SERVICE CHANGE • " 10.00
D
O c;i
LICENSED CONTRACTORS DECLARATION
s-Z w I hereby affirm(hat I am licensed under provisions of Chapter 9 ISSUANCE DATE
w (commencing with Section 7000)of Division 3 of the Business and
< N BLDG. ELECT. a PLG. MECH.
0 m Professions Co an license is in full ;
z o a - Licen ass =•' Lic.Number , ❑
a.N H� Dure� .�_Conlmclor '
le r f - BUILDING;,P�ERMI7
0 w a OWNIi R-BUILDER UIiCLARATION
O a u - INPOR�iIATION' r-T,,
,w ;u.r I hereby affirm ihat'1 am exempt from the Contractor's License MISC.— REFER TO ORD -
FuN'�
Law for the followingreason.(Sec. uires a,ermit tocnd Professions PERMIT ISSUANCE 6.00
'•VALUATION S/FT.
Code:Any city or county which structure Permit loconsuanc alter,
ce M ¢p improve,Demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
E
a u 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 _ �L�H
iii