11963 (3) T
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE LL POINT PEN ONLY
X BUILDING PROJECT IDENTIFIC N PERMIT NUMBER
BD, D,NG APPLICATION & PEWIT
ADDRESS�9 5 ,r .�-- : '^� B ILDING-ELECTRICAL-PLUMBING-MECHANICAL
11963
OwNER'g PLAN CHECK VALIDATION
N �• -�✓'�'�
PHONESd3 -3 89 OTY. ELECTRIC PERMIT FEE2--9,7
n
� S
NAME Op(
crony OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME r /
LIGHTING FIXTURES 10.00/1.00
LIC.No. L
f-ONTRAcroR's
ADDRESS /w_ PPLIANCES-RESIDENTIAL 4.00 /�0
/ /
O WLc!-QGlO Cil. PHONE 3S6-3894 PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CMELK FEE P.C.NO.
OR
ENGINEER
c.No. SIGNS TRANS. 3.00
ARCH.OR ENG. seSPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
zip EMP.METER OR POLE INS. 20.00 ^
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH,
`�/µ
J L SERVICE CHANGE 20.00
w
00 LICENSED CONTRACTORS DECLARATION I Vl
a L, 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
n a H (commencing with Section 7000)of Division 3 of the Business and BL ELECT. PLG.: MECH.
r N z Professions Code,a my license is in full force � ❑ ❑
.z 0 L - License C�a Lia Number
O w H te Date / _Contractor -
a BUILDING PERMIT
¢¢w
ai tOWNER-BUILDER DECLARATION INFORMATION
X
u y 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
VALUATION $/FT.
H LL O J Law for the following reason.(Sec.703 L5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
Sa ¢ a improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
A
O IF requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO I
Z-6
m he is licensed pursuant to the provisions of lire Contractor's License Iv_
iii