3868 (2) APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 3868
ADDRESS
BUILDING - ELECTRICAL-PLUMBING -MECHANICA
NAME 5, ./' PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE
l PHONF n
cONTR croS's � UTLETS-SWITCHES-RECEP 5.00/1.00 .
NAME
1,C,No. d' /�L LIGHTING FIXTURES 5.00/1.00
11
ry ACTOR'S PPLIANCES-RESIDENTIAL 4.00
ADDRESS p /J
BONE L Z PANELS 5.00 OATS OF APPLICATION
ARCHITECT SIGN$ 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEERNO, SIGNS TRANS. 3.00
ADDRESS ENG. - - SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ADDRESS - - '
ZIP EMP.METER OR POLE INS. 15.00
AooSESS
AppOCEMOTORS SEE FEE SCH.
ss •. -
X LICENSED CON'TRACTORS DECLARATION SERVICE CHANGE 10.00
'02 -
X u I hereby affirm that I am licensed under provisions of Chapter 9 D ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Businuss and LDG. ELECT. PLG. MECH.
H�i Professions Code n y license is in full force v?,efJ ct. O �e
z - License Cie Lic.Number_2o utL-h _�s _ O ❑ ❑ ❑
9 H w Contmcmr_/%.-x..�..�/6's((,oi fes'
rc ¢ w OWNER-BUILDER DECLARATION {� Jl� U ert,BU1LDIRMNG PERMIT
REFER TO ORDU. NFORMATION.
E:
LL I hereby affirm that I am exempt from the Contractor's License MISC.- VALUATION $/FT.
Hu0< Law for the following reason.(Sec.703L5,Business Professions PERMIT ISSUANCE .6.00 cy/
Code:Any city or can
which requires a permit to construct,alter,
QQ ¢ � improve,demolish,Or repair tiny structure,prior to its issuance,elso ELEC.CONTR. LIC.NO. ELEC. .3 YGl D• DO
- C ¢ aconites the applicant for such permit to fill a signed statement(flat TOTAL PER T TO
u w m. be is licensed pursuant to the provisions of the Contractors License
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