17813 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTIFICATION APPLICATION & PERMIT lSPERMIT NUMBER
HE ADDR
ADDRESSS F
20(05 S1 - LII UILDING - ELECTRICAL-PLUMBING -MECHANICAL ; 17 813
OWNER'S
NAME LJ'ywl'YJII-r� - PLAN CHECK VALIDATION
-rtf�i�`J PRONE_IJ3 /CY��.�OTV, ELECTRIC PERMIT FEE
I�L
NOMIRACTDR;f��r/ �ffLVY UTLETS-SWITCHES-RECEP - 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
D RA
As GI/�
EA.-OR W1� APPLIANCES-RESIDENTIAL 4.00
AD
�Ej SHONEPANELS IO.00 DATE OF APPLICATION
ARCHITECT I PLAN CHECK FEE P.C.NO.
on PANELS (OVER 200 AMP) 20.00
ENGINEER
tic,NO, SIGNS TRANS. 3.00 '
ARCHE08 ENG'. SPECIAL CIRCUIT $.00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
APPLICANT sMOTORS SEE FEE SCH.
AOOREss
SERVICE CHANGE 20.00
r o o LICENSED CONTRACTORS DECLARATION _ .3 �]ob'F `Q•J - -
G u I hereby affrm that I am licensed under provisions of ChaF9 ! 7- �Qt ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and -( F= s.�- BLDG ELECT. PLO. MECH.
F 0 i Professions Code,and my license is in full force and effect, PP
- Y
z - License ClassLic.Nllmlrar
o o`�'r o Date Conromtor
m a < OWNER-BUILDER DECLARATION BUILDING PERMIT
S o a u INFORMATION
K S H I hereby affirm that 1 am exempt from the Contractors Licevx .- ER TO ORD
LLoj