The URL can be used to link to this page

Home My WebLink About2287 WATERMAN WAY - Building Permits CITY OF COSTA MESA ry -. - BUILDING DIVISION r•4 ; 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us -. FOR INSPECTIONS CALL: (714)754.5626 4 PERMIT NUMBER: B08-00293 • PERMIT TYPE B_ROOF2 STATUS: ISSUED ' APN: 42604161 DATE ISSUED: 10/14/2008 ISSUED BY: BJK JOB ADDRESS: 2287 WATERMAN WY CM Suite/Unit:, Vicinity: RESIDENCE AND DETACHED GARAGE Squares: 3900 Valuation: $8,000.00 SCOPE OF WORK: REROOF RESIDENCE AND DETACHED GARAGE:TIO EXISTING COMP ROOF, REPAIR/REPLACE SHTG AS NEEDED, 2 LAYERS 15#FELT,APPLY"30-YEAR COMP SHINGLES."PITCH 3.5:12 3900 SO FT OWNER: HANSEN,MARK VICTOR TR Address: 321 E 23RD ST Unit: PHONE: . City/State/Zip: COSTA MESA,CA APPLICANT: ROBERT MORALICE Address: 2526 UNIVERSITY DR Unit: : PHONE: 949-4004752 • City/State/Zip: NEWPORT BEACH, CA • CONTRACTOR: OWNER-BUILDER License No. 000000 Address: Unit: PHONE: . City/State/Zip: CELL: ARCHITECT: License No. PHONE: ENGINEER: License No. PHONE: FEE SUMMARY • Reroof Plan Check: $0.00 Reinsp Ption Fe: $1$0.00 iti pReec insption Fee: $0.00 • TOTAL FEES $153.25 4 . NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§ 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. . INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. COPE I RN$IESJjON TYPS INnnAL$ SODS d !Panchen TYPE MT INTMAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical . 1266 Pool Spa Final208208 Final Plumbing 200 Final Re-Roof d-a'ro .y Q 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy i V •-, WORKERS'COMPENSATION DECLARATION: Owner• ID verified by drive. &pjres /Q.- I f ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' Verification of Ownership1 compensation, as provided for by section 3700 of the Labor Code, for the • b y(type of document,i.e.-property tax bill or deed): performance of the work for which this permit Is Issued. ❑ I have and will maintain workers'compensation Insurance, as required by ' • section 3700 of the Labor Code,for the performance of the work for which this DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: • permit is issued. My workers' compensation Insurance carrier and policy ❑ I hereby certify that no excavation five(5)or more feet in depth into which a number are: person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding.falsework,or demolition Cartier: or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2.Grp (Thisseton need no(be mnpetedl the perm!is valued al one hun&ddofars($I00)or less.) 2,Art2 Sec.341,Title 8,California Administrative Code). Policy Number: -- ❑ As owner-builder, I will not employ anyone to do work which would ❑ I certify that in the performance of the work for which this permit is require a permit from the Division of Industrial Safety,as noted above,unless issued, I shall not employ any person in any manner so as to become subject such person has a permit to do such work from the division. to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. Applicant's Signature Date Division of Industrial Safety Permit Number: Applicant's Signature Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? ❑Yes 0 No ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS (Section 25505 of the California Health and Safety Code requires,with some PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. INTEREST,AND exceptions, that a Business Plan be filed with the Costa Mesa Fire ATTORNEY'S FEES. Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of LICENSED CONTRACTORS DECLARATION: 500 pounds,or a volume of 55 gallons,or 200 cubic feet of compressed gas I hereby affirm that I am licensed under provisions of Chapter 9(commencing at standard temperature and pressure). with Section 7000)of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file my license is in full force and effect. a registration form for acutely hazardous materials? ❑Yes ❑No Lic.# Class# _ (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely Contractor's Signature Date hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard CONSTRUCTION LENDING AGENCY: temperature and pressure). ❑ I hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to performance of the work for which this permit is issued.(Sec.3097,Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely Lender's Name: hazardous materials)? 0 Yes 0 No (Section 25534 of the California Health and Safety Code provides that the Lender's Address: Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. Signature Dale 4. If an RMPP is presently required, has Section 25534 of the California OWNER-BUILDER DECLARATIONS: Health and Safety Code been fully complied with? 0 Yes ❑No I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, the work which is the subject of this application a permit for such construction Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from construct, alter, improve, demolish, or repair any structure, prior to its any other air pollution control district or agency? ❑Yes 0 No issuance,also requires the applicant for such permit to file a signed statement (Section 65850.2 of the Califomia Govemment Code requires that the requested that he or she is licensed pursuant to the provisions of the Contractors information be fumished on applications for non-residential building permits). License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and 6. Will any part of the facility to be constructed under this permit be within the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? ❑Yes ❑ No applicant for a permit subjects the applicant to a civil penalty of not more than (If'yes',the facility must meet the requirement of Sections 25534 and 42303 five h red dollars($500).): of the Califomia Health and Safety Code). ri I, as owner of the property, or my employees with wages as their sole 7. If a permit from the South Coast Air Quality Management District or other compensation. WILL DO THE WORK, and the structure is not intended or air pollution control district or agency is required for the work which is the offered for sale(Sec. 7044,Business and Professions Code:The Contractors subject of this application,have all of the disclosures prescribed by California License Law does not apply to an owner of property who builds or improves Health and Safety Code Section 42303 been made? 0 Yes 0 No thereon.and who does such work himself or herself or through his or her own - employees, provided that such improvements are not intended or offered for B. (If"yes",attach certificate of compliance from the appropriate air pollution rl sale. If, however, the building or improvement is sold within one year of control officer). • completion, the owner-builder will have the burden of proving that he or she CERTIFICATE OF COMPLIANCE: I certify that under'penalty of perjury the did not build or improve for purpose of sale.). information given above is correct. I agree to comply with all state laws and • ❑ I. as owner of the properly, am EXCLUSIVELY CONTRACTING WITH city ordinances regarding Hazardous Materials and Emissions. 4 LICENSED CONTRACTORS to construct the project(Sec.7044.Business and Professions Code:The contractors License Law does not apply to an owner of Signature Dale property who builds or improves thereon,and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I a contractor(s)license pursuant to the Contractors License Laws.). certify under penalty of perjury that I have read this application and state that 0 am exempt under sec. • the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of Business and Professions Code for this reason: the City of Costa Mesa to enter upon the above-described properly for inspection purposes. I agree not to occupy or allow occupancy of any building 1 �7 authorized by this permit until final inspection. j` �. r t('�--+-'�_O< /�$inature of Le Owner(s)( IO`Dale ��'�_1 `Signature \/ 'Date 1`C/` 0/ 3057-45(3.07) And/or Authorized Appl. nt (\Dale 2 DECLARATION OF AUTHORITY Bldg. Permit# FOR AGENTS OF PROPERTY OWNER TO APPLY FOR PERMITS This Permit# Street Ads s: f�� i /1 ' `� / AP Number: 1. f we), (`�u t./Ill ' / , , declare that I am the Owner of Title of the above referenced real property,and thai we)hereby authorize: Name: Pi//filt6-1 (phi-J .2 Telephone Number: Qv/!6e —11975-2— Street Address: &51QQ2 li// rci�%LJP1(\\JJ/l6tT�0�.LG(.e.J City: (J/ / '�� C a�/ State: K 7. Zip: /�U/40 to obtain permits in my behalf,as owner/builder,forjiii{/�,.�� at the above referenced property. 2. Should any person become an employee engaged in the improvement of the property, I (we)shall immediately provide Worker's Compensation Insurance coverage and cause a certificate of that coverage to be filed with the Building Division of the City of Costa Mesa,as required by State of California laws. 3. As owner/builder in fact, I understand and accept that my responsibilities do not transfer to any other person, company or corporation. 4. I agree to indemnify and hold the City of Costa Mesa and its employees or officers harmless from any claim resulting in damage or personal injury to myself or any other parties as a result of work authorized by the permits from the City of Costa Mesa. 5. I declare under the penalty of perjury that th foregoing is true and correct. Executed this / /I, day of �e to 20 6g-,at 6,762100 California. Print Name: Ill+nj u Ot I 1-4a Q'i stv1 Signature:Ga .(/a Q�i j'c /Nt �(%//l ' Date: /0/i�/ A/ (� Note: This authorization(does not grant authorization to perform the work as owner, it solely provides for limited power of attorney to secure this permit in any behalf. 0779-48(rev.l L00) F CITY OF COSTA MESA r fl BUILDING DIVISION F .,�i,g DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER � •8 PERMIT E00-01117 +� (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 2287 WATERMAN WY Status: ISSUED Suite No Applied: 11/27/2000 Vicinity: Issued: 11/27/2000 Parcel Nunmber: 42604161 Applicant: RAY, AMBURGEY ISSUED BY: `" Address: 817 W 17TH ST UNIT 9 Phone: (949)645-0729 COSTA MESA,CA Zip: 92626 Owner HANSEN, MARK VICTOR TR Address 321 E 23RD ST Phone: COSTA MESA,CA Zip: 92627 Contractor: ELECTRIC RAY Address: 817 W 17TH ST UNIT 9 Phone: (949)645-0729 COSTA MESA,CA Zip: 92626 License: 480485 SCOPE OF PERMIT SERVICE UPGRADE TO 200 AMP.AND 1 OUTLET. FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System/Lighting $0.00 0 Temp service test $0.00 Busway/100 ft $0.00 0 . Res.a/c package $0.00 . Standing Section $0.00 0 New Res(1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res(3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0 Pool/Spa $0.00 0 up to 10 kva/kw $0.00 0 Lighting Fixts $0.00 0 up to 50 kva/kw $0.00 0 Recept Outlets $1.10 1 up to 100 kva/kw $0.00 0 Switches $0.00 0 over 100 kva/kw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wring System/Ckt $0.00 0 Service to 200a $30.50 1 Misc.Conduit $0.00 0 Service to 1000a $0.00 0 Misc.Conductor $0.00 0 Service over 1000a $0.00 0 Circus(gen or ride) $0.00 0 Motors to 1hp $0.00 0 Circus(mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $55.10 Intermed Pole $0.00 0 COMMENTS/SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord. No.9228,§ 1, 12-21-92) EXPIRATION: This ermit shall automaticallyexpire and become void If work is not commenced within 180 days,p or if work Is suspended or abandoned for a period of 180 days. I\ INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 2448-46(6/00) DECLARATIONS • WORKERS'COMPENSATION DECLARATION: - I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit Is issued. My workers'compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars($100)or less.) I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' tcompensation laws o I o • ,and agree t t If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these pr isio -Appllcant:Sfgnature: Date:: I t - .2'Z- (r0 WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAG UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000).IN ADDITION TO THE COST OF COMPENSAT1 ,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affimtttiatkemlicensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of.the,Business and Professions Code,and my license is In full Hcforceandeec .a LI `rCles a C - I o Contractors$ignaturer �/1 Date: I r-2? -s-c-Th / CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lenders Name: Lenders Address: Signature: - - _ Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): ❑ I,as owner of the properly,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not appy to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: • Signature: Date: Owner ID verified by drivers license. ❑Yes 0 No Driver's License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application apermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? j�Yes CI No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 8 WIII any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If'yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (if"yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials end Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-descrty for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Weget Owner(s) Date .tAnd/Or:Authodzed-Appllca •=� —Date, CODE I INSPECTION TYPE PATE 1NTMALS CODES INSPECTION TYPE PAIL IITTTILU 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing I'�1,,�^^ —+ �s , 200 Final Re-Roof 210 Final Electrical �/30. PL-Fi;' f/ 201 Final Block/Retaining Wall 212 Final Fire Prevention / 7 / 6 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy go.Lte ..�t-71 -nau4«t ' -77A17.,;OAT._J„Z ,i 18015 rL : ilp.� ^ 1 ` c 1, COSTA MESA BUILDING-SAFETY DEPARTMENTid ‘ �/// 7� F DEPT, P. O. BOX 317 COSTA MESA. CALIFORNIA f'I' 1/� +�� For Applicant to Fill In Completely APPLICATION R IPERiy MI� A MESA TYPE OR PRINT BUILDING BUILDING ..aWa-kenbary Wei y ADDRESS X `.. p'/ A MESA. CA FORNIA For Office Use Only OWNER /1 4 EOM-It// /pjy^ 1I RECEIPT� N'OO.. /SII✓' /.P1 RSfII5 MAIL 3 �J �T / � RECEIVED(/✓ I D/9-in ll OC 7oTE 11V8U OC') ED ADDRESS /Sr�v,R_ B �� 1 /A• TECJ y 6 7 BUILDING /�� - CITM `-/ N -Ll0/Dy�, ADDRESS7(/�/i�Z ARCHITECT TEL.--__ '2 O COSTA MESA. CALIFORNIA OR ENGINEER NO. /� 0 Y FIRE �/�//J///1}�/1 ��I ZONE / TYPE (/ GROURY"�G' ADDRESS /e/I ✓"(/ C�l/l! CONTRACTOR APPROVED BY DATE ADDRESS ZONING ZONE/J NO.OF USE OF NEW X... • Da.,Az„ CITY - F(_ t I PLANS BUILDING [/j/ /-� OM" STATE 40 (02( NO. LEGAL 1 'T �/�/A7 LIC.Nq�,GX�GP .�Jb X DESCRIPTION Let- 6 I 7 �-/ / _ OF LOT //2 X 2 9. 1�SIZE e I NOW ON LOT NO. OF S 6 A.P.NO. USE OF 1YARDS EVES EXISTING BLDG, APPROVED ALLOWED SETBACK LINE FROM /^ /� (CENTER LINE ST.) _/J CENTER OF STREET •7 REAR YARD FRONT I FT. IN. SIDE YARD I LEFT J I RIGHT .2 / R.SIDE .5- FT. IN. DESCRIPTION OF WORK/ L.SIDE Z ] FT. I/� N. NEW I Z-V ALTERATION I II ADDITION I REAR / e FT. Leku-u.., IN. REPAIR I II MOVING I II DEMOLISH I APPROVED teri1,40 BY Pt DATE /O/��G \ BUILDING/L7 b 7 NO. OF / / /� n SIZE .4.2t ROOMS (� ORIES 77 C-� EXTERIOR WALL I ROOF -- COVERING COVERING /— /y [,-.r ,^, USE OF BUILDING AND WORK TO BE PERF RMED I HEREBuOWLE THAT I HAVE HIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION � AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM- PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. PLY WITH ALL CITY O INANCES D ATE LAWS REGULATING BUILDING CONSTRU ON. /Jp VALUATION SIGNATURE OF A�/� /�////A��/ PERMIT FEE $ �/ PERMITTEF i! //VV `t"'�F/L y��/1115/ N S PLAN CHECK $ `-25 L5?? AUTHORIZED AGENT �,S�3S- TOTAL FEE $ / Gi 37 4) 0