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Building & Safety Division ■ 91g0emtr } aW In Parcm-it 401-3218 • (805) 781-7180
Project Address 190 SANTA ROSA
Assessor's Parcel Number 001-031-028
Legal Description 009.82 AC RECREATION (PARK)
Project Description CELL SITE ANTENNA ADDITION TO TWO(E)POLES
& EQUIPMENT MODIFICATION - AT&T
Permit Type X Building X Mechanical X
Electrical X Plumbing Sign Demolition Grading
Property Owner CITY OF SAN LUIS OBISPO (940)
Occupant/Business Name SANTA ROSA PARK
Mailing Address 990 PALM ST
Architect/Engineer JONATHAN BEECHER MCALPIN
City/State/Zip SLO, CA 93401-3249
License # C-23402
Contractor SPECIALTY CONST INC
Contractor's Phone No. 543-1706
Mailing Address 645 CLARION CT
Contractor's State Lic. No. 619361
City/State/Zip SAN LUIS OBISPO CA 93401
Project Manager MICHAEL CLAWSEN @ OMNI
Project Manager's Phone No. 596-4263
Lender Name
Lender Address
C.B.C. Group B C.B.C. TypeV-B
Stories 0 Codes: CBC10 CEC 10
Census 437 Commercial Alteration or Addition
Dwelling nlJ Its 0 Motel Rooms 0
Valuation
Non -Residential Alteration
60,000 $60,000.00
Total Building Value $60,000.00
Fees
Le al Declarations
g
Building Permit
465.00
Plumbing+Electrical+Mechanical Permit
324.00
2a - CALIFORNIA LICENSED CONTRACTOR'S DECLARATION
Grading Permit
0.00
S. M. I. P.
12.60
Green Building Fee
3.00
1 hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9
Demolition Permit
0.00
commencing with Section 7000 of Division 3 of the Business and Professions Code, and
Sign Permit
0.00
my license is in full force and effect
Misc Charge/Credit 0.00 Administrative Permit
0.00
Contractor: SPECIALTY CONST INC Class: A. B. HAZ License #: 619361
Archival Fee
0.00
Subtotal 804.60
Investigation Fees
0.00
Building Plan Review Fee
707.00
Fire Safety Plan Review
0.00
Plan Review Subtotal 707.00
Development Review Fee
658.24
Fire Safety Surcharge
0.00
3a(2) - WORKERS' COMPENSATION DECLARATION - I have and will maintain
Fire Systems
0.00
workers' compensation insurance
Fire Sur/Sys Subtotal 0.00
Construction Unit Tax
0.00
Water Impact 0.00 Area
0.00
as required by Section 3700 of the Labor Code, for the performance of the work for which
Water Meter Installation
0.00
this permit is issued. My workers' compensation insurance carrier and policy number are:
Wastewater Impact 0.00 Area -
0.00
Carrier: TRAVELERS INDEMNITY OF Policy #:DTEUB6051 L7 Expires 10/01/11
Traffic Impact 0.00 Area -
0.00
Affordable Housing
0.00
Public Art
0.00
Code Enforcement
0.00
Park Improvement Area -
0.00
Engineering Development Review Fee
0.00
Open Space In -lieu Fee
0.00
Total Fees
2,169.84
Balance Due
0.00
Payments Y Fee Exemptions:
Amount Date Receipt
Payment#1
707.00
01/14/11 50017
Payment#2
1,462.84
02/25/11 50486
Comments:
Total Paid
2,169.84
Application Number110023
Permit Number 25300
Application Date
01/14/11
Issuance Date 09/28/11
Address File
Signature of Contractor, Authorized Agent or Owner Date