5295 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
40
0
8
e5
5
5295
0 .� BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OwNEH'B /N PLAN CHECK VALIDATION
NAM QTY. ELECTRIC PERMIT FEE
PHONE
NAMER RS ^�C OUTLETS-SWITCHES-RECEP 5.00/1.003
-'1„ Luc.No. LIGHTING FIXTURES 5.00/1.00
r, rRACTOR's PPLIANCES-RESIDENTIAL 4.00
ADDRESS 1 / '`
kku,,&. .PHONE 3(41^3 13 PANELS 5.00 S PATE OF APPLICATION
SIGNS 6.00 PLAN CHECK FEE P,C.NO,
OR
ENGIN
04 LIC..o. VIt 347 SIGNS TRANS. 3.00
AARCH,OR DDRESS ENG !! p SPECIALCIRCUIT 5,00 /r PERMIT VALIDATION
�/ •r zIP / EMP.METER OR POLE INS. 15.00
APPLICANT S - MOTORS SEE FEE SCH. 174
ADDRESS
SERVICE CHANG 10.00 O /o
wo o
LICENSED CON DECLARATION •r 24 -
o u I he rhy Annan that I um licensed under provisions of Chaple,91 ISSUANCE DATE
y a N . (connmancmg with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w z Professions Coda,ynl y cense is in full for'`a f
Z, O m- I icense L�V �.�`_ Lie Number
Q fw Ualc /)�S, Contractor
El a I El
P: Y s BUILDING PERMIT
w u OWNER-BUILDER DECLARATION INFORMATION
U, 0 g r 1 hereby firm ill t I um exempt from the Contractors License MISC.- REFER TO ORD
r LL o v, Law for the following reason(Seo 7031.5.Busiressand Professions PERMIT ISSUANCE 6.00 vALuaTION $/FT.
Code:Any city or county which requiresa permit tocons DGM alter,
� a, < 0 inlpmvo,Aemolish,o.repair any Wnlctu[e,prior to its issuance,also ELEC.CONTfl. LIG.NO. ELEC. /✓.�t OO
-y Oo u requires the applicant for such permit to file a signed statement Thal TOTAL 7�Vit PERMIT TO
A tam he is licensed pursuant to the provisions of the Contractor's License ?
F z i