HomeMy WebLinkAbout3492 WIMBLEDON WAY - Building Permitsr � �
� CITY OF COSTA MESA - - - �
B{IILDING D/VISION
F � 77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • wewv.ci.costa•mesa.ra.us
�. FOR INSPECTIONS CALL: (714) 754-5626
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PERMtT NUMBER: BC08-00364
PERMIT TYPE: B COMBO
Sub Type: RES_ALT
Joe,ao�RESS: 3492 WIMBLEDON.VIIY CM
aPN: a72oa3o5 � Zoning Rt
STATUS: ISSUED
DATE ISSUED: 09/10/2008
ISSUED BY: RMD
' Suite/Unit:, ..
Vicinity: ATTIC AREA .- Primary.Occ: R3
ConstType: V-g S�. FT:,- 428 �� Valuation: $30,000,00 .
SCOPE OF WORK: CONVERT 428 SF OF��1�SF FLOOR STORAGE AREA AND 2ND FLOOR ATTIC AREA (ABOVE GARAGE) INTO
HABITABLE ARpA. WORK TO INCLUDE: �CONVERSION OF 22 SF OF 1ST FLOOR FOR STAIRWAY, 406 SF OF 2ND FLOOR TO
HABITABLE AREA, CONSTRUCTION.OPA NEW DORMER, RECOCATE FAU, WATER HEATER, 1 REPAIR/ALTER
COOLING/HEAT, t VENT
FAN, 8 LIGHT FIXTS, 6 OUTLETS, 5,SWITCHES, 1-GAS OUTCET (1-4), 1� WASH BASIN, �1 WATER CLOSET. .
OWNER: SIHILLING,-CHARLES LAND BARBARA K Address: 3492 WIMBLEDON WAY "�� '�. . '; Unit: �
Phone: 714437-9580 ��- ' - � City/State/Zip: COSTA MESA, CA � - . � � '
APPLICANT: SIHILLING,�BARBARA K. Address: �- - Unit: : �
Phone: 714A37-9560 - . - City/State/zZip: � .
CONTRACTOR:
Phone:
Cell:
ARCHITECT:
ENGINEER:
OWNER-BUILDER :;-
�Address: Unit:
City/State:
License No. --
License No.
COMBINATION PERMIT FEE-SUMMARY
Building Plan Check: - � . $71.86
Building Fees: -�� $442.25
Eleclrical Fees: $44.40
Mechanical Fees: .- ', ,,,$3720
Plumbing Fees: " � �.��$49.25
SMIP Residential: $3.00 -
SMIP Commercial: $0.00
TOTAL FEES: $647.96
••Refer to fee receip}s (or all fees paid for prqect
License No. �000000 �
- � �� ZipCode
PHONE:
PHONE:
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requiremenLs under Califomia statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92) - �
EXPIRATION: PERMIT EXPIRES 780 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. ..
INSPECTIONS: In order for fhe work authonzed under this permit to be considered legal, such work must comply witFi all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expira6on o( this pertnit.
GODE t. INSPECTION TVE
1816 Fixed Systam Final Fire Prevention
1266 Pool Spa Firtal
200 Final RB-Rpp(
207 Fina181ocWReWining Wall
202 Final Factory Fire Place
203 Fina15ign
204 Final Demolition
Q,1,ET INIIML COOEt INSPECTIONTYPE
206 Final Mechanical
208 Final Plumbing
210 Final Electrical
272 Final Fire Prevention
220 Final Planning Approval
222 Final Site
250 FinalBuilding/Occupancy
DRTE . INIIMLS
.YII!- ► I �
;
WORKERS' COMPENSATION DECLARATION: '
1 hereby affirtn under penalry o( perjury one of the (ollowing declarations:
❑ I have antl will maintain a cerlifca[e o( consent to self-Insure for workers'
compensation, as providetl. for by section 3700 of the Labor Code, for the
peAormance o( the work for which Ihis permit is issued.
❑ I have antl will maintain workers' compensation insu2nce, as required by
sectbn 3700 of the Lahor Code, for the peAormance of Ilie woAc for v,fiich this
pertnil is issuetl. My workers' compensation Insurance wrner and policy
number are:
Carrier:
(ihis sequn nead nol0a cvmpleletl tlthe perm� is value0 a( one �untlied dollars (S �00) o� IessJ
P�o�licy Number:
L� I certify that in the perfortnance of the work lor which this permit is
issued, I shall not employ any person in any manner so as to become subjecl
to the workers' compensa[ion laws of Califomia, and agree �hat it I shoultl
become subjecl to Ihe workers' compensa[ion provisions of Seclion 3700 0(
the Labor Cotle, I shall forthwith comply with these provisions.
Appbonfs5ignature � � Dal O —
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVER4GE
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND OOLLARS
($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, IMEREST, AND
ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby aKrtn Ihat I am licensed under provisions ot Chapter 9(commencing
wilh Section 7000) of Division 3 of the Business antl Professions Code, and
my license is in full force and eflect.
Lic. # Class #
Comrac�or's SignaWre Date
CONSTRUCTION LENOING AGENCY:
❑ 1 hereby affum that there is a construcl'qn lentling agency (or the
periortnance ot the Hork ta which tNs pertnit is issuetl. (Sec. 3097, Civil Code�.
lentler's Name:
Lender's Address:
OWNER-BUILDER DECLARATIONS:
I hereby aRrtn that under penalty ol perjury thal I am EXEMPT FROM THE
CONTRACTORS LICENSE LAW lor lhe following reason (Sac. 7031.5,
Business antl Professions Code: Any city or county which requires a permil to
conslruct, alter, impmve, demolish, or repair any s�mcNre, prior to its
issuance, also requires Ihe applicant for such pertnit lo fle a signetl slatemenl
lhat he or 5he i5 liCensetl pursuant t0 the provi5ions o( the Contrattor5
License Law (Chapler 9(wmmenCing wilh SeCtiOn 7000) o( DiviSion 3 of Ne
Business and Professions Code) or Ihat he or she is exempt therefrom and
the basis for the allege0 exemption. Any violation o! Section 7031.5 by any
applicant for a permit subjec[s Ihe apPlicant to a civil penalty o/ not more than
five huntlretl tlollars ($500).):
❑ I, as owner of the property, or my employees with wages as Iheir sole
compensation, WILL DO THE WORK, and Ihe slructure is not intended or
offered for sale (Sec. 7044, Business and Pro(essions Code: The Contractors
License Caw does not apply to an ovmer of property who builtls or improves
thereon, and who tloes such vrork himself or hersell or through his or her own
employees, provided that such improvements are not intended or ottered for
sale. If, however, the building or improvemenl is sold within one year of
completion, [he owner-builder will have the burden of proving thal he or she
d�id n�ot build or improve for purpose of sale.�.
6drl, as ovmer o( lhe property, am EXCLUSIVELY CONTRACTING WITH
LICENSED CONTRACTORS ro construct lhe project (Sec. 7044, Business and
Pro(essions Code: The contractors License Law dces not apply to an ovmer o(
propeey who builds or improves thereon, and who contracls tor such project with
a cont2cta(s) license pursuant ro the Cont2ctors License Laws.).
❑ I am exempt under sec.
Business and Pro(essions Code (or this reason:
�� , i.��� � "�� � • • ♦
� �
Owner ID verified by Ariver _..,.ense. IdYes ❑ No
Driver's License�No. �$ Expires: 1���
Venfication of Ownership by (rype of document, i.e. - property lax bill or tleed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certi(y �hat no excavation frve (5) or more feet in tlepth into v.fiich a
person is required to descend, vrill be made in connection with work authorized
by Ihis pertni�, and that no building structure, scaffdding, falseHork, a tlemolition
or dismantling thereof, will 6e more than ihitly-six (96) feet high. (Chap. 3.2, Grp
2, Art 2, Set. 341, Title 8, Cali(ornia Administ2tive Code�.
❑ As ovmer-builder, I will not employ anyone to do work which woultl
require a permit from Ihe Division of Indusirial Safety, as noted above, unless
such person has a permit to do such work from the division.
AOD�iwn�'s Sigwwre Daie
Division of Industrial Salety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will Ihe applicant or present or future building occupant need to file antl
certify a Business Plan for emergency response to release or threatened
release of a hazardous material7 ❑ Yes ❑ No
(Section 25505 0( the Calilornia Health and Sa(ety Cotle requires, wilh some
exceptions, thal a Business Plan be filetl with the CosW Mesa Fire
Depariment by every business which has at any one time tlunng a repotled
year a quantily of hazardous materials equal to or grealer lhan a vreight of
500 pountls, or a volume of 55 gallons, or 200 cubic feet of compressed gas
at slandartl lemperature an0 pressure).
2. Does or will the applicant or presenl or (uture building occupant need to file
a registration form for acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the Calitomia Health and Safety Cotle, with some
exceptions, requires registration vrith the Cosla Mesa Fire Department by
each business v+hich at any one time has on �anG a quantity of acutely
hazartlous materials equal to or greater than a weight of 500 pounds, or a
volume o( 55 gallons, or 200 cubic feet of compressed gas at slantlartl
temperature antl pressure�.
3. Does or vrill the appliwnl or present or fuWre building occupant neetl to
prepare an RMPP (Risk Managemen[ and Preven[ion Program for acutely
hazardous materials)? ❑ Yes ❑ No
(Section 25534 of the California Health and Sa(ety Code provides ihat the
Costa Mesa Fire Department may require the preparation, certifica[ion antl
filing wilh Ihe Fire Deparimen� of an RMPP by businesses which are requiretl
to register acutely hazardous materials with the Fire DepaAment.
4. If an RMPP is presently required, has Section 25534 of the Califomia
Health and Salety Cotle been fully complietl with? ❑ Yes ❑ No
5. Does or will the applicant or present or fWure building occupant require for
the wVrk which is the suDject of ihis applicalion a permit for such wnstrUction
or modification from the South Coasl Air Quality Management District or from
any other air pollution conlrol Oislrict or agency? ❑ Yes ❑ No
(Sectbn 658502 of the Califomia Govemment Cotle requires ihat the requested
infortnation be tumishetl m applicalbns ta non-residential building permits).
6. Will any part of Ihe lacility to be wnstructed under this pertnit be within
1000 feet Irom lhe outer boundanes of a school? ❑ Yes ❑ No
Qf "yes", ihe faciliry must meet the requirement o( Sections 25534 and 42303
of the Calilomia Health and Safery Code).
7. If a permit (rom Ihe SoWh Coast Air Qualiry Managemen� District or other
air pollulion control district or agency is required for the work which is the
subject ol this application, have all of the disclosures prescribed by Califomia
Health and Safery Code Seclion 42303 been made? ❑ Ves ❑ No
8. (I('yes", anach ceAificate of compliance from Ihe appropnate air pollution
control officer). � � �
CERTIFICATE OF COMPLIANCE: I certify lhal under penalty, of perjury the
information given above is correcL I agree lo compty with all state laws and
cily ordinances regarding Hazardous Materials and Emissions. � '
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certify untler penalty of perjury that I have read this application and sWte Ihat
lhe information given is wrrect I agree to comply with all slate laws antl city
ordinances relating to building construction, and authonze �representatives of
Ihe Ciry ot Costa Mesa to eMer upon Ihe above-descnbed property (or
inspection purposes. I agree not to xcupy or allow occupancy ot any building
auth �zed by Ihis perr�LL.t�yl f I i p �on.
—\` �p
SlgnaWreolLeBaiOwneqs) _ . � e p`-'
Ana/or Aul�orizetl Ap0liwnl Date
(714) 754-5273 • Fax (714) 754-4856 • www.c�.costa-mesa.��LDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626
JobAddress: 3492 WIMBLEDON WY
Suite:
Vicinity: HOUSE AND GARAGE ROOF
PrimaryOcc: R3
Parcel Number: 41204305
,4pp�icant: AKIL, ABDO
Address: 3303 HARBOR BLVD
COSTA MESA, CA
owner: SIHILLING, CHARLES L
Address 3492 WIMBLEDON WAY
COSTA MESA, CA .
� , .
, 'i
Contracroc :DKAM ROOFING
Address: 3303 HARBOR BLVD
COSTA MESA, CA
Zip: 92626 , .
Arch :
Address:
Zip:
Phone:
License:
Type of Constmction: V-N
Zoning: R1
�
Phone: 714-641-1440�
Zip: 92626 �
DP
Phone: 714-437-9560
Zip: 92626
Phone: 7'14-641-1440�
F�+� I,
License: 841611 ��
Eng:
Address:
StaWs: ISSUED
Applied: 10/06/2006
Issued: 10/O6/2006
Phone:
License:
SCOPE'OF PERMIT
TEAR OFF (E) ROOF MATERI,4LSD, INSTALL t LAYER OF 30# FELT ON A 9:12 PITCHED ROOF, REROOF W/GERARD METAL ROOF (1.5PSF)
ESF 1491 ON ATTACHED HOUSE AND GARAGE, APPROX 3,OOOSF. REPAIR AND REPLACE SHEATHING AS NEEDED.
, FEE SUMMARY
Plan Check: $0.00 - Calc Valuation: $ia,zoo.00
Permit:
SMIP Res:
SMIP Com:
Other:
Inspection:
Total:
$251.25
$1.42
$0.00
$0.00
$0.00
$252.67
SETBACKS ,
MAINSTRUCTURE.Front 0-0 Rear 0-0
� , I . . ,
ACCESSORY Front 0-0 � Rear 0-0
PARKING �� � Existina: . 0�� - Reauired: 0
PLANNING & ZONING
Left 0- 0
Left 0- 0
Pr000sed: 0
Claim Valuation: s�a,zoo.00
0
Right 0- 0
Right 0-0
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)
EXPIHATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned
for a period of 180 days. �' - .
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 Inspeetlona and final approval must be obtained. Failure to obtain inspections and final approval will result in Ihe expiration of this permit.
FOR INSPECTIONS CALL: (714) 7545626
2A46i6(NW�
WORKERS' COMPENSATION DECLARATION: -
I heraby eNlrm under Denelty of pe�ury one oi ihe tollowing decleretlans:
❑ I have end will melntaln e certlflcete of consent to selt-Insura tor workers' compensatlon, es Orovided for by sectlon 3700 of the Lebor Code, for the pertormence of the
work far whlch this pertnit Is issued.
❑ I have and will maintain workeB' compensatlon insurence, es requiretl hy section 3700 of ihe Labor Cotle, for the peAortnance of Ihe work for which this pertnit is Issued.'
� My workere' compensatlon Ins nce �er end pollcy number ere:
L��C ���� � Policy`Number.> �'f1�L('�7_7_F�O�
not be cromplefed il the permit is valued ef one hundred dollars ($100) or less.) ji--=� ---
❑ I certify ihat in ihe paRortnence of the work for which this pertnit is issued, I shall not employ eny person in any manner so as to become su6ject to the workers'
compensation law f Celifomia, entl egree that if I shaultl become subject to the workers' compensation provisions of Section 3700 of Ihe Labor Code, I shall forthwith
complYwilhthese vision
�plicen�ignawre: � Date: l0 - b —��o
WARNINO: FAIL E WORKE SATIqJ COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDRE�
TiIOUSAND OOLLARE (5100,OW), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PFOVIDED FOR IN SECTION 3]O6 OF THE LABOR CODE, IIJrEPEST, ANO ATiORNEV'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby aHirm that I am licensed under provisi<
CONSTRUCTION LENDING AGENCY:
oi Chapter 9(commencing with Sectlon 7000) of Division 3 of Ihe Business and Protessions Cotla, end my license Is In full
Class k � � - � "�
Date: �� O- c., .- o C_
❑ I herehy ettirm ihat ihere is a consiruction lentling agency tor the pedormance of the work for which ihis permit is issued. (Sec. 3097, Civil Code).
Lentler's Neme: LentleYs Atldress:
Signeture:
OWNER-BUILDER DECLARA710NS:
Date:
I here6y eHirtn that under penalry of perjury that I am EXEMPT FROM 7ME CONTRACTORS LICENSE LAW for iha tollowing reason (Sec. 7031.5, Business antl Protessions
Code: Any ciry or counry whic� requires a pertnit to construc6 elter, improve, tlemolish, or repair any sWcture, Orior to its issuance, also requires the applicant tor such permit
to file e siqnetl statement ihet he or she is licensed pursuent to ihe provisions of the Contractors Licensa Law (Chepter 9(commencing with Sectlon 7000) of Division 3 of [he
Business end Professions Code) or thet he or she is exempt therefrom and the besis for ihe elleqed exemption. Any violation oi Section 7031.5 by any epplicant for e permit
subjects lhe epplicant to a civil penelty M not more lhan five hundred dollars ($500).):
❑ I, es owner oi the propeny, or my employees with wages es Ihelr sole compensation, WILL DO THE WORK, entl ihe structure is not intendetl or ottered for sale (Sec.
7044, Business and Professions Cotla: The Comractors License Lew does not apply to en owner of properly who builds or improves thereon, and who does such work
himseN or herself or ihrough his or her own employees, provided ihat such improvements ara not intentletl or oHered for sale. N, however, Iha building or improvement is
soltl wit�in one year of completion, ihe owner-builder will heve ihe 6urden ot Droving ihat he or she did not build or improve for purpose of sale.).
❑ I, es owner of Ihe property, em E%CLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct ihe project (Sec. 7046, Business and Professions
Cotle: The contrectors License Lew does not appty to en owner of pmperty who bullEs or Improves thereon, and who contracts for such project with e contractor(s)
license pursuant to lhe Contractors License Laws.).
❑ I am exempt under sec. Business and Prolessions Code tor this reason:
Signe�ure: Dete:
Owner ID verifietl by tlriver's license. ❑ Ves ❑ No Drivefs Licensa No.
Verilicetion of Ownership by (type ot document, i.e. - property tex blll or deed):
Expires:
�IVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hareby certity ihat no excavation five (5) or more feet in depth imo which a person is required to descend, will be mede in connection wit� work authorized by Ihis
pertnit, and that no building siructure, scattolding, falsework, or demolition or dismantling thereot, will be more than thirty-si: (36) feet high. (Chap. 3.2, Grp 2, Ah 2, Sec.
341, Tllle B, Califomia Atlministrative Code).
❑ As ownervbuiltler, I will not employ enyone to do work which woultl require a permit imm the Division of Industriel Satery, as noted ebove, unless such person has e
pertnit to do such work from Ihe division.
Signeture: Dete:
Division of Industrial Safery Permit Number.
CERTIFlCATE OF COMPLJANCE AND AIJTHORIZATON OF ENTHY: I certity under penalry ot perjury that I have read Ihis application and state �hat ihe information given is
correct. I egree to wmply with ell state lews and ciry ordinences relating to building construdion, antl authorize representatives ot the Ciry of Casta Mesa to enter upon the
above-descnbed properry for inspection puryoses. I agree not to occupy or ellow occupancy ot eny building authorized by this permit until finel inspedion.
LOOE 1. INSPECTIONTYPE
1616 Fixed System Final Fire Prevention
1266 Pool Spa Final
200 Final Ra-Roof
201 Fine181ocWRetaining Wall
202 Final Factory Fire Place
203 Flnal Sign
204 FinalOemolition
QSIE INTIMLS
COOEt INSPECTIONTYPE
206 Final Mechanicel
208 Final Plumbing
210 Final Electrical
212 , Final Fire Prevention
220 Final Planning Approval �
222 Final Site
250 Final Building/Occupancy
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DEPARTMENT
FORNIA 92626
For Applicant to Fill in Completely - Use Ink Only
ADIDRESS 3492 Wimbledon Way
OWNEROR Wimbledon �15SOC.
TENANT
ADDREs 1470 Jamboree Rd
c�Tv Newport Beach No`'640-680
� oER�'o"Imperial Savings & Loan
BRANCH Pasadena
AODRESS 6�. S. Lake �iV2
ADDFE55 17992 Mitchell So.,Irvine
CONTFACTOFMCLd1R Dev. Co.
ADORESS �.4%� Jamboree FiC�
cirv Newport Beach No�40-6800
uc No. 273875 uc�No. 18873
SIZE NO.OF BLOGS.
OF LOT NOW ON LOT O
Separate permits are required for
electiic, plumbing and heating work.
PRD - New construction
Single-family dwelling
1 hereby acknowletlge that I have raatl this application antl state
that tha ebove intormeNon is correci and aB�ee to comply with
all laws regulating builtling consttuctlon, antl 1 shall not amploy
any penon in violation of the workman's compensatian laws ot
the Staie of Celitornla.
I hereby cerHty [hat 1 am prOparly Iicansetl es a contrector untlar
the Stnte at Colitornia Business entl Profassions Cotla, Division 3,
Chapter 9, end t�et such licansas ere In full force antl afiect, or 1
am axampt irom the provisions of the State of Californie Business
and Professiona Cotla ivision 3, e ter C
SlBnatura ot ./
Parmittee '/
or
Authorizad ABant Date
��07 �i2liel, zi,+,.3o i�,�
, -
APPLICATION FOR STRUCTURAL PERMIT
RECEI VED BY PERMIT N� - 4 7 7 71
A.P. No. - �. a.-- o
BUILDING
ADDRE55 ZdQ7 Wim1
UNIT OR
SPACE NO.
TR.NO. LOT
NEW � ADD IALTER �REPAIR
OWNER
USE
VALUE
3
ED �� � onrF I I2
APPROVEDSETBACKS
P�-
PLANNING ACTION
�� �/J ^�.J j � APPROVEC)'y �
HOLD FOR SPECIAL REQUIREMENT`
m
n
i
m
t✓ SQ. FT. � �`+ �
THE AMOUNT S WN UNDER VALUATION IS FOR m
THE PURPpSE OF ESTABLISHING A PERMIT FEE ONLV: ��
VALUATION PERMIT FEE S �+ v �
N
� �
PLAN CHECK S m
g�r g y� �Y�
r�1 �� TAX E .7 (J U V
✓
TOTAL PAI D E'� �,%�� �a �
OWENS-CORNING
Fiberglas
Blanket Insulation
The contractor named below certifies that the Owens-Corning Fiberglas
Blanket Insulation used carries the NAHB Research Foundation, Inc. label
for assured thermal performance and that the Blanket Insulation is in-
stalled in conformance with current energy conservation regulations,
California Administrative Code, Title 25, State of California, in the building
located at:
.- ,���, � i �/�� �;` �� �.' �]\-
,.
� Street � Lot Number Tract Number
Exterior Walis 3/ . —�
Owens-Corning Fiberglas Blanket Insulation /
Thickness R-Value
Ceilings /„ �
Owens-Corning Fiberglas Blanket Insulation (� �
Thickness R-Value
Floors
Owens-Corning Fiberglas Blanket Insulation
Foundation Walls
Manufacturer
Thickness R-Value
Type Thickness R-Value
General Contractor License No.
By Title Date
(Slgnawre)/ �% � • )
Insulati ntr tor_ �� /�'+ > � �%% � -+' �� *��License No..1�_��
/] /
By _ . _ _ . Title j�`/ Date - � �
is� �a��,ei
Homeowner Copy (White)
State Copy (Yellow)
Builder Copy (Pink)
Pub. No. ifi-BL699bA Lil�o rn U.S.A., July 19))
OWENS-CORNING FIBERGLAS CORP.
Insulation Operating Division
Fiberglas 7ower, Toletlo, Ohio 43659