12853 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - U�BALL POINT PEN ONLY
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BUDDING APPLICATION APPLICATION & RMIT
AD�Es nnOs PEG' BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 12853
OWNER'S I"Kv ! yF V PLAN CHECK VALIDATION
1 NAME TV
f CRFIRI aS R }►Av' ,HONE 57-44,ro ELECTRIC PERMIT FEE
corvrxacroRs Qyx, UTLETS-SWITCHES-RECEP 10.00/1.00
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ADDRESS APPLIANCES 4.00
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PHONE PANELS M0 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER IbIDAMN 20.00 PLAN CHECK FEE P.C.NO.
OR
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uc:No SIGNS TRANS. % 3.00
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ADDRESS
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°w o o LICENSED CONTRACTORS DECLARATION
a i u 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
mi Professions Code,and my license is in(all force and effect. ElEl 1:1o i m W License Class Lic.Number
H Datc Contractor
a y s BUILDING PERMIT
E z w a OWNER-BUILDER DECLARATION INFORMATION
wa Aea MISC.- REFER TO ORD
g; a.o, 1 hereby affirm that I am exempt from the Contractor's License
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