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1. TYPE OF ACTION (Check One):   New Structure   Add / Demolish   Repair / Alter   PERMIT NUMBER:

2. PROJECT LOCATION:  STRUCTURE:      LOCATION OF ROOM(S) / PROJECT: 
    DESCRIPTION OF WORK:
    
    PROJECT VALUATION (Including all fixed operation equipment):
    
    DESCRIPTION OF ANY ATTACHED DOCUMENTS:
    

3. DEPARTMENT:  
    CONTACT:     ENTER PHONE & FAX:
    DIRECTOR:   ENTER PHONE & FAX:

4. ARCHITECT/ENGINEER:
    ARCHITECT:    ENTER PHONE & FAX:
    ADDRESS:       CALIF LICENSE #:
    ENGINEER:      ENTER PHONE & FAX:
    ADDRESS:       CALIF LICENSE #:

5. AREA:
    AREA:     OCCUPANCY INCREASE?  YES     NO  
    PARKING:      ADD'L PARKING PROVIDED?  YES     NO  

6. CONSTRUCTION:
    CBC TYPE OF CONSTRUCTION:  I     I     II     III     IV     V  
    OCCUPANCY:  A     A     B     E     F     H     I     R  
    NUMBER OF STORIES:     FOUNDATION/STRUCTURE:  
    FIRE SPRINKLERS?  YES     NO     EXT BUILDING ENVELOPE:  
    FIRE ALARM REVISIONS REQ'D?  YES     NO     ROOF SYSTEM:  

7. AGENCY/CAMPUS REVIEW:

    CBC PLAN CHECK:        DATE:     ENTER FEES:  $    DATE:  
    STRUCTURAL CHECK:    DATE:     ENTER FEES:  $    DATE:  
    DSA:                            DATE:     ENTER FEES:  $    DATE:  
    CSFM:                          DATE:     ENTER FEES:  $    DATE:  
    LAFD:                           DATE:     ENTER FEES:  $    DATE:  
    CEQA:                          DATE:     ENTER FEES:  $    DATE:  
    PPM:                             DATE:     ENTER FEES:  $    DATE:  
    TELECOM:                     DATE:     ENTER FEES:  $    DATE:  
    E H & S:                        DATE:     ENTER FEES:  $    DATE:  

8. APPROVAL & SIGNATURE:

    APPLICATION APPROVED BY:  

    SIGNATURE: _____________________________________    DATE: _______________

    PRINT NAME:     TITLE:

    Revised 9/2006