HomeMy WebLinkAbout575 WENDY LN - Building PermitsApplicant to till in all spaces ezcept tnose within heavy boraer lines ana sign all apvro0��ate aeclarations.
CITY QF COSTA MESA CONSTRUCTION PEFiMI I oFa nin rancr Nn i nT rvn � ����T ���,
� '� Project Address ' J� s. e �—
�ApplicanYsMailingAfddre �� �r� �
Owner's Name �S �jn Phone `s �
' Address � � ���. S � / �
� Arch/Eng. License No.'
Address
r
Contractor's Name � Phone V1
Address (ma�i��n� O �3 " �� 4 ,�%/� �'- i / � �
Ciry Licema Nn 7 '?-.�
LICENSED CONTRACT00. DECLARATION
I hereby affirm that I am licensetl untler provision5 of Charter 9(commencing
with section 7000) ot Division 3 01 the Business antl Profeszions Cotle, antl
my license is in full e antl ettect. � �p
Li[ens las �G � en No u`7/) %
Date - Signature
WOi3KER5' COMPENSATION DECLARATION
1 1 hereby affirm that I have a certificate of consent to self-insure or a certificate
i` Workers' Compensation Insurance, or a certifietl wpy thereof (Section
� 100, Lab. . Y� �
�olicy No. - �' � � Company �����, r u%��
er[ified copy i5 hereby fumishetl.
, Ce Y ieQ�coe� is fileG with the city Bµi� ' is' n.0 i �
Date�.'6y_�L— Applicant � L/Li��
EXEMPTION FROM WORKERS' COMPENSATION DECLARATION
(This section need not be rompletetl il the permit is for one huntlretl (g100) or
less).
I certify that in the performance ot the work for which this perm�t is issuetl, I
shali not employ any person in any manner so as to become subject to the
Workers' Compensation Laws of California.
Date Siqnature
NOTICE: It, atter making this tledaration, you shoultl bewme subject to the
Workers' Compensation provisions ot ihe Labor Cotle, you mu5t forthwith
comply with such provision5 or this permit shall be tleemed revoked.
CONSTRUCTION LENOING AGENCV �,r"`,�
I hereCy affirm that there is a construction lentlin9 agency for tM1e pe�formance
01 the work for which this permit is issuetl (Section 3097 Civ. CJ
Lentler's Name
Lentler's Atltlre55
OWNER BUILOER OECLARATION
I here�y atfirm that I am exempt from the Contracior'S LicenSe`0L'aw tor the
following reason (Section 7031.5 Business antl Professional Cotle4=Any city or
munty wM1iclt �equires a permit to construct, alteq improve, tlemoll5h or repai�
any structure, prior to its i55uance, also �equires the applicant for'such pe�mit
to fiie a signetl statement that he/she is licensetl pursuant to ihe'provisions ot
me Contractor's License Law fChaoter 9 fcommencina with Section ]0001 of
= p;da,¢refrom antl the basis for the allegetl exemption. Any violation of Section
"q}�131.5 by any applicant for a permit sub�ects the appli<ant to a cWil
:""Talty of not more than five huntlred tlollars ($500).
���L� I, as owner of the properfy or my employees with wages as their Sole
compensation, will do the work, antl the structure is not intendetl or offeretl
for sale (Section ]044, Business antl Protessional Cotle: The Contractor's
License l�w tloes not apply to an owner ot a property wno builds or improves
thereon,-antl who tloes such work nimselt/herself or through his or ner own
employees, providetl that such improvements are not intentled or offered for
sale. If, however, [he builtling or improvement is soltl within one year ot com-
pletioq the owner will have the burtlen ot proving h¢/she tlid nat builtl or Im-
' prove for the purpose of sa�e). �
❑ I, as owner of the property, am exclusively cont�acting with licensetl Con-
tractors to construct the project 15ection 7044, Business antl Professions Cotle:
The Contractor's License Law dces not apply to an owner ot property w�o
builtls or improves thereon, antl who contracts far such projects with a con-
Irac[or(s) I¢ente pursuant to the Contractorh License �aw). I am aware that
prooi of their Worker's Compensation insurance shoultl be providea to me.
❑ I am exempt untler Section H. & P. C, for this reason
Date Owner
I hereby certify that I have read tnis application antl state that the above
intormation is conect. I agree to comply with all city antl wunty ortlinances
antl state laws relating to builtling construction, antl hereby autho�iie �epre-
sentatives ot this city [o enter upon the above-mentionetl p�operty for
inspection pu e
Signature Date /rl,� _Rk
DriSers' License or 55 �
TVPE OF CONSTRUCTION � LJ NEW IJ ADD LJ ALTERATION L� REPAIR
❑ CONVERSION ❑ DEMOLISH ❑ OTHER A p. #
� DESCRIPTION OF WORK/USE OF BLDG.
� S Main Building:
TVPE OF PERMIT �❑ GRADING� �❑��/y p�UNoaTiOrv ❑ STRVGTuaAL T Front
❑ TENANT ❑ ELECTRICAL L7 PLUMBING ❑ MECHANICAL B R¢af
❑ OTHER %�
PROJECT DESCRIPTION SQ.FT. OCCUPANCV C Right
K Left
CONSTRUCTIONTYPE VALUATION$ $
ZONE GRADING CU. VDS. ACRES Ping. Ref. #
Remarks: Planning Notes:
Sink
<flow Preventer
<flow Irriqation
Clarifiers
Dishwasher
Drinking Fountains
Floor Drains '
FloorSinks
Gas Service Outlets
Interceptors
Kitchen Sink
Lavatories
P—Trap
Roof Drains
ReinspeMion Fee � $15
Boiler
Duct - Under Ground
Duct - Sttuctural
Duct - Ventilating
Exhaust System ❑ Multiple
Firepi/Fact. Blt. ICBO #
Heating System & Ducting
❑ 0-100,000 BTU � 100,000
peinspection Fee � $15
CMF 0865-46, rev. 10/84 WM1ite - Builtling; Canary - AppliWnt; Pink - Atcountinq; Goltlenrotl - A55e55or
Showers
Service Sink
Sewer Cap -
Sewer Connection
Solar Collectors
Solar Piping
Solar Tank
Swimming Pool w/Spa
Urinal
Water Closet
Water Heater
Water Service
A uto-W ash
Issue Fee
Hood or Typel ❑
Canopy Type 11 ❑
Refrigeration System
❑0-100,0008TU ❑t00,000BTU
System Repair/Alteration -
Fire Dampers
Registers
luue Fee
FEES
Zone.
Accessory Building:
Parking Req./Provided
ELECTRICAL
Automatic Washer Transformer ❑ 15-50 KW
Construction PoleSuh. � - � 50+KW
Cooking Unit
Dishwasher -
Dryers ❑Gas ❑Electric
Fan
F.A.U.
Fixtures
Device Boxes
Outl¢ts
Switch¢5 '
Garbage Oisposal
Generator �0-5 KW 05-15 KW
Meter LJup to 100 amps
Meter ❑over100amps �
Su6 Panel
Momrs �0-1 HP �1 %- 8 �
Inc.Solar �9-15 HP �i6-15+
Microwave
Pole Light
Range
Sign
Standing Sections .
Trash Compactor
$ 3 I _
�— Reinspection Fee $15 Issue Fee
FEES
�DEVELOPMENT SERVICES REQUIREMENTS:
Zoning Approved By
Building Approved By
Aoolication Issued Bv
$ 3
Z
Q
N
I
N
G
R
E
Q
M
T
S
FEES
$ 3
' SUMMARV OF FEES .
BUI�DING PERMIT $ SMIP $,
PCAN CHECK $ PERMIT
PLUMBING $ � �SSUANCE $ �—
PLAN CHECK 25% $ ENERGY P.C. $
ELECTRICAL $ GRADING $
PIANCHECK 50% $ MICROFILM $
J
MECHANICAL $ TOTAL FEE $ �
PLAN CHECK 25% $
_ ?,�3<17/8E tIt?E: 02
a_
CONSTRUCTION AND�"PLANNING . POOL & SPa
APPROVALS Permit�# Date Inspector � qppROVALS Permit# Date Inspector
.i
7. Temporary;Electrical'Service or Pole 52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd�. • 53. Steel Reinforcement
3. Electrical Conduit Utility-Undrgrnd. 54. Forms
4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding C.^. ,
-• �
c�
AVOlicanl to fill in all s
CITY OF COSTA MESA PERMIT NO.
CON_S�RUCTION PERMIT p� �
Address
' - _ - License Na.
� ..
within neavy Dortler lines antl sign all apvropriate Oeclarations.
TRACT NO. LOT NO. BLDG. NO.
TVPE OF CONSTRUCTION �
❑ NEW ❑ ADD ❑ ALTERATION L
❑ REPAIR ❑ CONVERSION ODEMOLISH
❑ OTHER
DESCRI7TION�OF WORK
. , 0473" "I/I I�/82 ' 18.00 TL
h .ct � "
Contractor � `��.�,�� - - Phone - TVPEOFPERMIT . .
Addre55 - � _ � . ❑ GRADING - � C�FOUNDATION' STRUCTVRAL -'-
LICENSED CONTRACTOR DECLARATION ' ❑ TENANT 0 ELECTRICAL' CUMBING ❑MECHANICA
I hereby atfirm that I am Ilcensetl untler provislons o( Charter 9•(com- '
mencing with se[tion.]000) of DlviSion" 3 ot the Business antl ❑ pTHER ' -' "�^ - -
Professions Cotle; antl� my Ilcense is In �ull forte antl eftect. �-'
License Ciass - � License No. ' ' PROJECT DESCRIPTION' � -- - . .. _ ..
Date Signature � � - " 5�. FT. � ' - .. .
" i. ,
WORKERS',COMPENSATION�DECLARATION - - � OCCUPANCV_CONSTRUCTIONTVPE.
I h¢r¢by aflirT that I have a'certificata of con5ent to self-insure Or a VALUATION ' 20NE
Certifiwte of Workers' �Compensation Insurance,'or a-cer[ifietl Copy -. .
thereof (Section 3800,'Lab. CJ. F GRADIIVG CV. VDS. ACRES �
Pollcy No. Company � - --� - ' - -
i�°',tertl(ied copy is hereGy turnisnetl. ' - . REMARKS: • -- � - --- .._ _ __
� '^er[ifietl <opynis filetl witM1 the-city_Builtling Division. _
c��EMPTION FROM WORKERS' COMPENSATION DEClA0.ATION � � ` ' - �" ' " -' "
(Tniz SeGtion' neetl not be�Complet¢tl if the permit-IS for one nuntlretl _ _ . _ _ . . . _ _ _
(§300) or leu).: ,� ' - . i ' �. '
I certify that Im tne;perto�mance of-the wo�k�fo�-which this pe�mit is. ,_ _,
Issuetl, I shall not empioy any person in any manner so as.to bewme ' PLUMBING ,- .. +: PLAIV CFIECI( - --�
subiect to the�Workers' Comoensation Laws o( California. -- -
Date � Signature BATHTUBS
NOTICE: If.after making this tleclaration, you shoultl become subjec[ TOILETS�. ,f;
to the Workers' Compensation provislons of the Labor Cotle, you mu5t
torthwith comply with such provistons or this permit sM1all be tleemetl LAVATORIES
revoketl.. , . _ . � . _ .' �" " ' _ _ ' "' "
CONSTRUCTION LENDING AGENCV KIT. SINKS
I hereby affirm that there is a construction lending agency for the per- SERVICE SINKS
tormance of the work for_which tnis permit is issued (Section'309�
Civ. C.1. � ' �' ' - -
l.entler:S.Name .'F�OOR SINKS
Lentle�'s Atltl�ess DRINKING FOV
OWNER BUILDER DECLARFTION � INTERCEPTOR'
I hereby affirm that I am ezempt t�om the Cont�attor'S License Law for
[he following reason (Section ]031.5 Business antl Professions Cotle:' SWIMMING1t�
Any city_o� county whi<h require5 a pe�mit [o con5t�uct, al[e�,
i tl I'h
SHOWERS
�� URINliLS
DOUBIE LAVS�
DISHWASHERS
' SUMPS
"F.LOOR ORAINS
JNS '
�CLARIFIERS
mprove, emo is or repair any structure, pnor to i[s issuance, also re- yyqTER SERV ICE ALTERATIO�
qui�eSlh¢ ap'.licant for suGh_pe�mit to file a signetl statement that he
(Ctlapter_ 9(comrtlencing wi[h_Sec[iOn �000) of OiviSion 3 of Ih¢
Busin¢55 antl Profe55ion5 Cotle) o� tnat he I5 exempt therefrom antl the
basis Por lne.allegetl exemption. Any violation of Section 7031.5 by
a�"' applicant for a pe�mit subjects [he applicanf to a civil penalty
�Lmore than,five huntlred tlollars (E500).
� as owner of th¢ property, or my employees with waqes as thelr
Smctompensation, will�tlo the wo�k, dntl the�5tructure is not intentletl
or oft¢retl for sale. (Section ]044, Business antl Professions Cotle: The
Cont�aCtor'S License haw tloes not apply to an owne� ot a O�ope�ty
who builds o� improves thereon, and who tloes Such work himself or
througMhis own employees, provitletl-[hahsuch improvements.are not
Intentletl or offeretl for sale. If, however, the builtling or improvement
Is�soltl'within one�year of �complelion, the owner will have the burden
bf provinq he tlitl not builtl or improve fo� tM1e purpose of SaIC).
❑ I, es owner of tfie'property, am exclusively mnt�actinq-with
licensetl contractors to consVuct [he project (Section 7044, Business
dntl Professions COGe: The Conlractor'S License Law doe5 not appry to
an owner of property who builtls or improvEs thereon, antl who con-
lracts iroin iuch proiectz with a'contractor(s)' licesnea' pursuant to
the Contractor's License Law�.
� I am exempt untler Section B. 8 P. C. tor this
reason
Date'-8-e�� "Owner O / m
I hereby certify [ha41 have reatl this-application antl State tnat the above
intormafion is correcL I agree to compty with all city an0 county
ortlinances�antl�state laws relating t0 ConSt�uction, antl he�eGy authorize
represen[atives 1 tni city [o enter upon the above men[ionetl
GASSERVICE OUTLETS
WATER HEATERS� BTU OVTPUT
SEWER CONNECTIONS � � � `
SOLAR TANK � � � COLLECTOR°
SOLAR PIPING SVS. - -
ISSUE FEE (
MECHANICAL P�nn c�iECK
HEATING SVSTEM 0�300,000 BTV _
ANDDUCTING 100,000,+BTU_
REFRIGERATION 0-100,000 BTU_
SYSTEM 100,00a + BTV _
BOILERS BTV
SYSTEM REPAIR,ALTERATION
EXHAUSTSVSTEM_ MULTIPLE
property- � e�n 'ib � . _ /.` J�
Slgna[ure e � �
Drivers' License or 55 �F � � � ISSVE FEE -
CMF0865-46 White-Builtling;Canary-Applicant;Pink-Accounting;Goltlenrotl-Assessor
�
��
1 "' _
REGULATIONS • �
ZONE PLNG. REF. � .
wTRiTI'r: � rn oi in nir.ir . ..
REHR VARD (TO P/L) �
�PKG.SPACEREQ. �-PROVIDED�, . �`
STREET WIDTH PARK FEE §, -
ZONINGAPPROVEDBV,- - 'DATE . ' , �
SPECIAL CONDITIONS: , , ,� , , .
_ ' _ "" _ ' _ " _
�.
ELEC7RICAL � - �P�lirveHECic�- ��
GENERATOR 0-1 KW_1-10 KW
TRANSFORMEft � � .
�APPLIHNCE 30-50 KW=50 + {(W J
1MOTORS " � p.l HP '_1-10 HP . '
pN0. SOLAR) -. 30-50 HP-=- 50'+ HP � .•.
�FIXTURES� OUTLETS "'SWITCHES " " -
GAS TUBE'SIGNS - -' " ' ' '
i
POLE�LIGHT$' - " -" ' ' . '
POLES METERED SUB� �
PANE�S �� - - ' MAIN � SUB " '
�SERV I -- " - ' - AMP' - `
_ _ _ _ l
- "' ' . . - . . ' " _ '"" . �
j ISSUE FEE ' ' ` ' ' -'
.ACGLICATIONAPP0.0VEDBY --- '- -- DATE }�
SUMMARY OF. FEES , ,�,
'BUILDING"- " ' - - . . .. -•� , .,__ +
PERMIT.. $ ' p' /SMIP,��.. , $' - 1
n.:. 1
. PLAN CHECK `§ ^ / PERM�T �� "�
� �� V ISSUANCE �8� ���, � I
�P�UMBING 8._52� �;q - •.
G RADI NG. .5 �
'PLANCHECK 5"�' � � J • . E �
ELECTRICAL S � ' �"L� � - .-
PLANCHECK '$ � MICROFILN $ •
� 'TOTALFEEE� �
MECHANICHL,$ - ' � - - .
�PCAN CHECK E � — � LE55 AD- ' __
' VANCEPC 8_ �
� . _ FINALFEE $�i�•OD
. ,. � POOL�&SPA . . t . ..,.` -
CONSTRUCTION ANDPLANNnIN,G- ��--�c�� ' -,
APPROVALS Permit # LG�6.42 Date Inspector � qppROVALS � Permit# �' y�' •�Date 'Inspe'�mr�,
1. Temporary Electrical Service or Pole � - 43. Pool & Equipment Location �- � - 1�jj.
2. $oil ipe-Undrgrn � • � ' 44. Steel Reinforcement - -��
� 3._. Electrical Conduit Utility-Undrgrn 45. Forms �.�
4. Electrical Conduit-Undrgrn � 46. Electrical Bonding � '
. tee ein orce -�• - 47. Rough Plumbin & Pressure Test :
6. Electrical UFER Grn ' 48. APPROVAL TO COVEfl-GUNITE ' "� �
7. Footings - ' � ' ' 49. Electrical Condu't-Undr rn . � -$ �
_ 8. Poundation. ' � �50.. _Gas P.ipe, ndr rn, Test � ' . (J
9. Water Pi e-Undr rn "' --�
P 9 51 . Backwash Lines P-Tra - � Undr rn
10. Structural�Floor System . � ' 52. APPROVALTO DECK -� -
11. Property Sewer Line & House Connection �' 53. Backwash & Rece tor-Final � -� `
. 12. Street Sewer Connection '���� 54.. Heater.&�.Vent�Final '
13. Rough Plumbing - = � � -- � - � �
- 14. Rough ElectricConduit --- - -- -- �56.- �Electrical-Final- - - -�
15. Rough Electric-Wiring � � -� - , -- -- �- -•- - - 57.-�SolarSystem-Final � = � ' -� •�� � � �
1�6. Rough Heating &-Air Conditioning - Fencing & Access Approval �. �j'
' 17. Ducts; in Structure . -� � ' '' S9• APPROVED FOR PLASTERING � ' -f' �
18. Ducts, �Ventilating ' _ _ '- � � � '
19. Gas Pipe-Rough & Test � ' - _ ' 60. POOUSPA SYSTEMS FINAL . '� ' . , /�� pG
_ / �l
20, Roof Framing _ � � � � � � �
21, Roof Sheathin �' ' � ' . ' . _ .. . . . . � . -.
z2. Frame and F�ashin � � NOTES: ' ' � � �
23, Insulation - � G
' 24, Lathing & Siding - ' � '
25, Drywall Nailing ' ' ` -
� 26, Plaster Brown Coat � ' � �� � - '� ' � - ' '
, 27, Electrical Power MeterFinal � • • ' '' � � � � ' � '
• 28. -- Final Electric � ' ' � ' - � ' � � '
� 29�, Final Heating & Air Conditioning. ' ' � ' � '
30, Final Gas Pipe-Test . � ' � ,
31._Final�Plumbing � �
-32�. _Water Service-Final ' � • � '
� 33. Gas Service-Final � � � � ' �
34, Solar pomestioFinal '• ' • � - � � '
. 35. Landsca e S rinklin S stem � � -' '� '
36. Sound Attenuation � � � � � � � " '
37. Handicap Regulations ` � � � ' � ' � �
• 38. FINALSTRUCTURE,&BUILDING � � ' '
� 39. Special Requirements Completed ' � � � - � ' '
' 40. Electric Release to Edison - ' - '"
41. Gas Release.to Southern California Gas Co. - � - '� �
42. CERTIFICATEOFOCCUPANCY � _ _ '
No.__.� Date � ' - � ,
- f 45821
�i ��� �
COSTA MESA BUILOING-SAFETY DEPARTMENT
P.O. 60X 1200 COSTA MESA, CALIFORNIA 92626
For AppGcant to Fill in Completely — Use Ink Only
BUILDING �
ADDFESS Ma � Q .�}MQTICIT
owNEdohn R. Davies & Son
MAIL
ADDRESS
GITV Santa Ana NOL 751-5
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BRANCH
ADORESS
ARCNITEGT
ORENGIN ER A.D.S.
AOORESS 4Q] E. j]t
CONTRACTOR (lwncr� _
AODRESS j]7(� F
c�rv Santa Ana
STATE
UC. NO.
OF LOT 21 X rjG
USE OF
CITV
LIC. NO.
$eparate perrtti[s are required for
electric, plumbing and heating work.
garage
92L4 t;/�t�/7E IDGa04 TL
92^4 4/14/73 106o0�sC1(T(J
92%:4 �Oli[7Lf'.59^I I!!
APPLICATION FOR STRUCI'URAL PERMIT
flECEIVEDBV DATER�GEIVE DATEISSUED
ADDRIESs�� Mapl e I1YC'�~ �
f1
R John R. Davies & Son
FIRE
a_ 20NE
APPROVED
1-9930
DATE
NO. OF
PLAfS 2
APPROVED
BUILDING
I
� TGN FT.
FT.
BEf. MAIN &
ACGE.Q. BLDCaS.
��Q� �T� �
v APPROVED 3 a
i�i1 /_ ._�.2_
t hereby acknowletlpe ihet I hevo raetl t�if ep0��cation end ttate
thnt the ebove Informatlon Is eorroct antl naroa to comply with
ell laws re0ulatlnp bulltlinp constructlon, antl I shell not smpioy
ony percon �� ��oletlan of the workmen's companaetlon lewa ot
tho Stete of CelHornla.
I horabV eertify thet 1 em properly Ilcanwtl as e eanttoeto� unde� Sn' �
tha Smto o� Celifornie Buainw and Prof�alon� CoEe, Dlvislon 3, THE AMOUNI
Chepur 9, antl thet such Ilcanaaa era In full foree anA offxt, or I TNE PURPOSE i
om onompt ftom tha provlslonsof thsStem of Celifoinla Busineu VALUATION
ontl Profess�ona Cotle, Divialo eDter 9. (n
Sipnat�ra oT / /�� "� _ y�,J �
Permlttee ��V � S
A�thorixotl �1penT
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m
' N3
VN UNDER VA UATION IS FOR m{�
'ABLISHING A PERMIT FEE ONLV: �
PERMIT FEE 3 N
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PLAN CHECK S O o�
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TAX f � q 1 ,�
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TOTALVAID 3 � �;
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COSTA MESA BUILDING-SAFETV DEPARTMENT
P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 ) � � � 6�•2���8 � 6��0�
APPUCATION FOR STRUCI'URAL PERMIT"'� �
Eor Applicant to Fill in Completely — Use Ink Only qECE1VED Bv DATE RECEIVED o E i
BUILOING '�-/� �� ��
ADDRESS ��L �
PERMIT NO.
OWNER �/��'y'� A.P. NO.
M.�.I l BUIIDING
ADDRESS ADDRESS
TEL. TRACT LOT BLOCK
CITY NO.
DONSTRUCTION � A
LENDER
BRANCH
OWNER
ADDRESS VALUE
ARCHITECT TEL. S S
R ENGINEER
FIPE
ADDRESS ZONE TVPE GROUP
APPROVED
CONTRACTOP BY DATE
ADDRESS
TEL. ZONE NO.OF USE OF NEW
G�TV NO. P�� BUILDING
yTATE CITY �'ARDSAPPflOVED YARDSAPPROVED
41C. NO. LIC. NO. MAIN BUILDING ACCESSORV BUILDING
512E NO.OFBIDGS. (FROMC/LSTFEET)
pF LOT NOW ON LOT RONT FT. FT.
USE OF
EXIS'fING BLOG. FT
Separate permits are required for � si E FT. FT.
electric, plumbing and heating work.
REAR FT. FT.
USE OF BUIIOING AND WORK TO BE PERFORMED DISTANCE BET. BET. MAIN &
MAIN BLOGS. ACCESS. BLDGS.
VAR.qW DATE
C.U.P.y►� qPPROVED
APPROVED
� hereby acknowletlpa thet I have reatl this epplieatlon and state '^
n
thet the ebove InformeNon is corract antl aB�ee to comply with m
ell laws repulatinp buildlnp consvueNon, and I shell not omptoy
ony person in violation of Me workmnn's compenseHon lawa of ^
the Scete ot Celifornie.
m
herob cartif thet I am SQ. FT. n
I Y y VroPerly Iicensatl es e contractor unCer �
t�e Stata of Celifornlo Businasa and Profeaione Cotla, Dlvlaion 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR
Chapter 9, and thet such Iteanua ere in full forca and affeet, or 1 THE PURPOSE OF ESTABLISHING A PERMR FEE ONLV: ��
em anampt from the provisionsoi theStata of California Buainau VAIUATION PERMIT FEE E a
entl Professlona Coda, Dlvislon 3, Chapter 9. m�
PLAN CHECK �� ^�
S�Bneture of �
Purmittee S TAX S ,./�� f
U
puthorizad ABant TOTAL PAID E