HomeMy WebLinkAbout3059 MADISON AVE - Building Permits •
•
Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations.
CITY OF COSTA MESA ‘ PERMIT NO. TRACT NO. LOT NO. BLDG. NO.
CONSTRUCTION PERMIT /� y� Q - /a SR.0 . -,.
�� 108-&11i�kl [J�+ s TYPE OF CONSTRUCTION ❑ NEW ❑ ADD H ALTERATION ❑ REPAIR
Project Address //��,,,�, pper�/p I�,,ttJ� ^^ ,,naA�
Applicant's Mailing Address .Iaeo C_ornr . .A .1 C414.• ❑ CONVERSION ❑ DEMOLISH ❑ OTHER A.P.# y OLine 14/26/04 16.50 TL
A �j DESCRIPTION OF WORK
Owner's Name N I��" )-L SS�� Phone, O � J S Main Building: Accessory Building: 2
ap t W)l4I2LSN Ave- C,1A't, 0
Address �7 �J 1 j TYPE OF PERMIT LI GRADING U FOUNDATION U STRUCTURAL T Front N
Arch/Eng. License No. TENANT ❑ ELECTRICAL ❑ PLUMBING ❑ MECHANICAL BA Rear I
Address ,,..nn - / OTHER �°E-1200PIly t / G
Contractor's Name r�.A�K-. ��W• r.5i7 ^Phon^e, 33o-9 PROJECT DESCRIPTION Sq. FT. /(Q� OCCUPANCY p,e� C Right .
Address(mailing)_tab -I �) (-•IY`' CONSTRUCTION TYPE n . VALUATION$ .Zo1[Vi� $ Left R
City License No. W 619-3 Ping. Ref.# Park.Fees $
OD
ZONE GRADING CU.YDS. ACRES 0
U
LICENSED CONTRACTOR DECLARATION Remarks: Parking Req./Provided I
I hereby affirm that I am licensed under provisions of Charter 9 (commencing R
with section 7000) of Division 3 of the Business and Professions Cod: and Use of Building: E
my license is in ful fort a•• effect. '
Ucens: Class .f _ i -1, s`p+ O / PLUMBING FEES Planning Notes: M
nate - •-TO Signet.,1 err'. 4.. _Alec j - N
In\ ' Bar Sink Showers
)RKERS'COMPENSATION • to of co ON • T
�I Hereby affirm that I have a ltate of consent to self-insure er a certificate Backflow Preventer Service Sink S -
QJ of Workers' Compensation Insurance, or a certified copy thereof (Section
3800, Lab. C.. �� ) -�}/� Backflow Irrigation Sewer Cap ELECTRICAL FEES
Policy No. ops Company.2-424-)1I tT - -
"`••iii"' Certified copy is hereby furnished. Bathtubs Sewer Connection. Automatic Washer Transformer 0 15-50 KW
\: Cer 'ti tl py etl with the cit II slAry,, �,.�rr
\ _ Date- � Applicant {'f.� . K.(=�r Clarifiers Solar Collectors Construction Pole Sub. ❑ 50+KW
- . EXEMPTION FROM WORKERS'COMPENSATION DECLARATION Dishwasher Solar Piping Cooking Unit Meter ❑up to•100 amps
�- - (This section need not be completed if the permit is for one hundred ($100) or •
\ 'leis):
I certify that in the performance of the work for which this permit Is issued,ISolar Tank Dishwasher Meter Cover 100 amps
shall not employ any person In any manner so,as to become subject to tDrinkingiFountains
e • -
Workers' Compensation Laws of California. Floor Drains. Swimming Pool w/Spa Dryers ❑Gas ❑Electric Sub Panel I
Date Signature -
NOTICE:If,iafter making this declaration, you should become subject to the Floor Sinks Urinal Fan - Motors 00.1 HP 0115-8
Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked. , Gas Service Outlets ' Water Closet ' F.A.U. Inc.Solar 09-15 HP 016-15+
CONSTRUCTION LENDING AGENCY - - - - _- — •
I hereby affirm that there is a construction lending agency for the performance Interceptors • Water Heater Fixtures 'Microwave '
of the work for which this permit is 'issued (Section 3097 Civ. C.) _
Lender's Name Kitchen Sink Water Service 4 ' Device Boxes Pole Light
Lender's Address Lavatories •
OWNER BUILDER DECLARATION Outlets Range •
I hereby affirm that I am exempt from the Contractor's License Law for the p-Tra
following reason (Section 7031.5 Business and Professional Code: Any city or p •
- Switches Sign
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 Roof Drains Garbage Disposal • Standing Sections
'•o file a signed statement-thathe/she is licensed pursuant to the provisions of - '
e Contractor's License Law(Chapter 9 (commencing with Section 7000)of - Generator 00-5 KIN❑5-15 KW Trash Compactor
.vision 3 of the Business and Professions Code) or that he/she Is exempt
•
Ii lerefrom and the basis for the alleged exemption. Any violation of SectionI -
7031.5 by any applicant for a permit subjects the applicant to a civil Reinspection.Fee $25 Issue Fee $ 3
penalty •
•
of not more than five hundred dollars($500).
UI, as owner of the property or my employees with wages as their sole • . MECHANICAL Reinspection Fee $25 Issue Fee $ 3
compensation, will do the work,and the structure is not intended or offered , . FEES
for sale (Section 7044, Business and Professional Code: The Contractor's •
PUBLIC SERVICES REQUIREMENTS:
License Law does not apply to an owner of a property who builds or improves Boiler Hood or Type I 0 •
thereon, and who does such work himself/herself or through his or her own Zoning Approved By - - Date •
employees, provided that such Improvements are not Intended or offered for . -- • Canopy Type II ❑ l -
Duct-Under Ground
sale. If, however,the building or Improvement is sold within one year of com- Building Approved By I, Date ./ //
pletion, the owner'will have the burden of proving he/she did not build or im- Duct-Structural Refrigeration$ stem , Application ation Issued By /`� y �'" !t/�G/�T
orove for the purpose of sale). 9 V PP Date
I,as owner of the property, am exclusively contracting with licensed con- ❑0.100,000 BTU ❑100,000 BTU
tractorstb construct the project (Section 7044,Business and Professions Code: Duct-Ventilating _ S
,- SUM ARY FEES _
The Contractor's License Law does not apply to an owner of property who -
builds or Improves thereon, and who contracts for such projects with a con- ' Exhaust System 0 Multiple 0 System Repair/Alteration _ BUILDING PERMIT $ - /a • Q SMIP- • $ 'd
tractor(s) license pursuant to the Contractor's License Law(. PLAN CHECK $ PERMIT
•
❑ lam exempt under Section B.& P.C.for this reason Firepl/Fact Blt. ICBG#• PLUMBING $ ISSUANCE $
Date Owner Heating System&Ducting , ENERGY P.C. $
PLAN CHECK 25% $
I hereby certify that Ihave-read-this application and state that the above 00.100,000 BTU ❑100,000 BTL - ELECTRICAL $ GRADING $
information is correct. I agree to comply with city and county ordinances
and state laws relating to I in constructs and hereby authorize repro- • PLAN CHECK 50% $ MICROFILM $
sentatives o his city t ter pon the ave-mentioned q@roperty for _
Signere u o f q _ - MECHANICAL $ /•••...5 7�
Signa oLt"/' Date TOTAL FEE $ �t� 0
Drivers"L cense or 55 - Reinspection Fee I $25 .Issue Fee $ 3 PLAN CHECK 25% $
CMF 0865-46 rev.12/83 White-Building;Canary-Applicant;Pink-Accounting;Goldenrod-Assessor - - •
' CONSTRUCTION AND PLANNING POC •SPA - - ,
Date . Inspector - . Date . Inspector
APPROVALS Permit# - APPROVALS ' Permit# -
1. 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 - - •
5. Steel Reinforcement 56. Rough Plumbing & Pressure Test - - -
6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE, • 7) •
7. Footings 58. Electrical Conduit-Undrgrnd. .'
B. Foundation - , 59. Gas Pipe, 0 Undrgrnd.,Test' i - ' -
9. Water Pipe-Undrgrnd. - 60. Backe✓ash Lines,.P-Trap,-0 Undrgrnd.• . - , -i ,
10. Structural Floor System 61. APPROVAL TO DECK - � _ l
11. Property Sewer Line & House Connection ., 62. Backwash 1& Receptor-Final: • - .
12. Sewer Cap 63. Heater& Vent-Final - •
13. Roof Drains - 64. Plumbing System -Final - - -
14. Rough Plumbing 65. Electrical-Final - - - _
15. Rough Electrical-Conduit 66. Solar System-Final - -' -- - " - - '
16. Rough Electric Wiring67. Fencing & Access Approval = - -- ;
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING'
18. Rough Electrical-T Bar Ceiling 69.. POOL/SPA SYSTEMS FINAL '
19. Rough Heating & Air Conditioning , ,FIRE DEPT. REQUIREMENT -
20. Rough Factory Fireplace APPROVALS' Permit# - • ' -
21. Ducts, in Structure 70. Underground Hydro -
22.4Ducts, Ventilating 71. Product Piping 0 Gas,!0 Oil i ri I
4
232 Gas Pipe-Rough & Test ' 72. Underground Flush
24? Roof Framing 73. Undergrnd.Storage Tank'0'Gas'0 oils. I 'P' ' '
25. Roof Sheathing - - 74. Overhead Hydrb
26. T-Bar Ceiling (Structural) & Monocoat - 75. Dry Chemical '
27. Frame and Flashing ,76. Dry Standpipe - ' •
28. Lathing& Siding '-. 77. FIXED SYSTEM FINAL '� .
29. Insulation 78. FIRE PREV. FINAL •
30. Drywall Nailing HEALTH DEPT. REQUIREMENT '
31. Plaster Brown Coat 79: FINAL INSPECTION '
32. Electrical Power Meter-Final , 80., FOOD CERTIFICATE ISSUED I
33. Final Electric ! Notes:* Rs E-Re F Cr? 5 H FAD Roo FS IN,
34. Final Heating & Air Conditioning
RRAR ONLY-- J(Fe- - -
•35. Final Gas Pipe-Test '
36. Hood or Canopy - _ .
37. Final Factory Fireplace . - - a -
38. Final Plumbing
39. Water Service-Final
40. Gas Service-Final '
41. Solar Domestic-Final , ' - - - - - - - - - '
42. Backflow Preventer •
, - ' • - •, -
43. Backflow Irrigation
,
44. .Landscape Irrigation System ' - ' ' I l
45. Sound Attenuation , - •� l - '
•
46. Handicap Regulations • ' 1
47. FINAL STRUCTURE & BUILDING* /_.S U zyy, _249, 1 i i I , -
48. Special Requirements Completed , , -
49. Electric Release to Edison
50. Gas Release to Southern California Gas Co I , '
i
51. CERTIFICATE OF OCCUPANCY - - - -- ---i-- - - . .
No. Date ' _ _. . . - _ , - - -
42A \---
Tv
/ Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations.
TY OF COSTA MESAfj CONSTRUCTION PERMIT PERRMI O. 9/ TRACT NO. LOT NO. UNIT NO. A P # Zone At
Project Address ?Q5– / Pica i on l G3�4 y�JPS4. - /i�S AT6 S Main Building: Accessory Building:
Apniic6nl's Mailin Address VA me . TYPE OF CONSTRUCTION NEW U ADD Li ALTERATION U REPAIR E Front • Z
'� �–ey '11 ❑ CONVERSION ❑ DEMOLISH ❑ OT ER T O
OwnpeT's Name 1�-Q`r Phone) JI-- �`1.,7 iv DESCRIPTION OF WOR./USE e F :LD -. `u f.-;•1/2R.- f.-;•1/2R. 4-7(q4-7(q_.t – cb�J- I B Rear • - N
Address �• (CL+ • • r -
Arch/Eng. License No..] 1 D y5,(,(0r —b TYPE OF PERMIT N GRADING El FOUNDATION STRUCTURAL C Right _ – N
Address ❑ TENANT ❑ ELECTRICAL ❑ PLUMBING ❑ MECHANICAL $. Left R
Contractor's Name CG', PAC g�C� Phone 9�)"lqIS ❑ 'OTHER Ping. Ref. Parking Req,/Provided E
PROJECT DESCRIPTION SQ. FT. 9 1 Cao OCCUPANCY g 3 Q
Address(mailing) I c2>13 N ' cs�"1G"' C\CA^�LPlanning Notes:
CONSTRUCTION TYPE VALUATION$ rB so M
¢2 3i T
City License No. ZONE GRADI NG CU.YDS. ACRES S.
LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Charter 9 (commencing Remarks:
with section 7000) of Division 3 of the Business and Professions Code, an W -
my license is in I I f.rr_ Livens- N. /i
and effect. r1,/Cyf� ELECTRICAL FEES
License Class
Date:I– `
– •-- • Signature ' e • •Ilei ], . PLUMBING FEES Automatic Washer • Transformer 0 15-50 KW •
WORKERS'COMPENSATION DEC ARATIONBar Sink Showers Construction Pole Sub. ❑ 50+KW
I hereby affirm that I have a certificate of consent to self-insure or a certificate
-f Workers' Compensation Insurance, or a certified copy thereof (SectionBackflow Preventer Service Sink Cooking Unit Meter ❑up to 100 amps •
800, Lab. C.) •
Policy No. Company Backflow Irrigation Sewer Cap Dishwasher Meter Dover 100 ainps
Certified copy Is hereby furnished. • Dryers ❑Gas ❑Electric Sub Panel -
_ Certified copy Is filed with the city Building Division. Bathtubs Sewer Connection '
Date Applicant '•
Fan Motors 00-1 HP ❑1X-8
EXEMPTION FROM WORKERS'COMPENSATION DECLARATION Clarifiers Solar Collectors •
(This section need not be completed if the permit Is for one hundred ($100) or F.A.U. Inc.Solar 09-15 HP 016.15+ -
less). Dishwasher Solar Piping • -
I certify that in the performance of the work for which this permit is issued,I Fixtures
shall not employ any person in any ner so as to become su ect to the Drinking Fountains Solar Tank • Microwave
Workers Co.a7q,5nsation Laws of Cali o /� /q��/�
•
Date I -K.i"a0 Signature aM4- -n- C-a'+/)sl-.'- Floor Drains Swimming Pool w/Spa Device Boxes Pole Light •
NOTICE: If,after making this declarati n, you should become subject to.the Outlets Range Workers' Compensation provisions of the Labor Code, you must forthwith Floor Sinks Urinal _ 9 .-
comply with such provisions or this permit shall be deemed revoked. .
CONSTRUCTION LENDING AGENCY Switches Sign Gas Service -Outlets Water Closet 9
I hereby affirm that therewhiis a permit
lending agency for the performance
C.e
of the work for which this permit iz issued (Section 3097 Civ. CJInterceptors Water Heater - Garbage Disposal Standing Sections •
Lender's Name '
Lender's Address ' Kitchen Sink Water Service • Generator 00-5 KW 05-15 KW Trash Compactor
OWNER BUILDER DECLARATION •-
I hereby affirm that I am exempt from the Contractor's License Law for the Lavatories Auto-Wash -
following reason (Section 7031.5 Business and Professional Code: Any city or
county which requires a permit to construct,alter,improve,demolish or repair P–Trap Laundry Trays - • -
any structure, prior to its issuance, also requires the applicant for such permit
to file a signed statement that he/she is licensed pursuant to the provisions of Roof Drains • - '
the Contractor's License Law (Chapter 9(commencing with Section 7000) of
'Division 3 of the Business and Professions Code) or that he/she is exempt _ Reinspection Fee , $15 Issue Fee $ 3
erefrom and the basis for the alleged exemption. Any violation of Section -
31.5 by any applicant for a permit subjects the applicant to a civil
-nalty of not more than five hundred dollars($500). DEVELOPMENT.SERVICES REQUIREMENTS: -
I
-❑ I, as owner of the property or my employees with wages as their sole Reinspection-Fee I • $15 Issue Fee $ 3 Zoning Approved By Date
.compensation, will do the work,and the structure is not intended or-offered 1 • -
for sale (Section 7044, Business and Professional Code: The Contractor's MECHANICAL FEES _. Building Approved By Date
License Law does not apply to an owner of a property who builds or improves ' - , 2.189
thereon, and'who does such work himself/herself or through his or her own - – - Application Issued By Date
employees, provided that such improvements are not intended or offered for Boiler _ Hood or Type I 0
sale- if, however, the building or improvement is sold within one year of cpm- Canopy Type II ❑ SUMM RY OF FEES
pletion, the owner will have the burden of proving he/she did not build or im- Duct-Under Ground •
prove for the purpose of sale). - ' - BUILDING PERMIT $ 6/700 SMTP $ ' S-0
❑ I, as owner of the property, am exclusively contracting with licensed con- Duct-Structural Refrigeration System PLAN CHECK $PERMIT
tractors to construct the project (Section 7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who Duct-Ventilating 04100,000 BTU 0100,000 BTU PLUMBING $ ISSUANCE $
builds or improves thereon.and who contracts for such oroiects with a con- - • -
tractor(s) license pursuant to the contractor's License Law). I am aware that Exhaust System 0 Multiple 0 System Repair/Alteration PLAN CHECK 25% $ ENERGY P.C. $
proof of their Worker's Compensation insurance should be provided to me.
-� GRADING $
❑ I am exempt under Section B.& P.C.for this reason Firepl/Fact.BIt. ICBG# Fire Dampers • ELECTRICAL $
PLAN CHECK 50% $ MICROFILM $
Date owner Heating System& Ducting RegistersI CD
I hereby certify that I have read this application and state that the above - 00-100,000 BTU ❑100,000 BTL - - _MECHANICAL $ TOTAL FEE $ O
Information is correct. I agree to comply with all city and county ordinances ' PLAN CHECK 25% $
and state laws relating to building construction,and hereby authorize repre-
sentatives of this city to enter pon the above-mentioned property for
inspectio• T,poses.
Signature cw nv'• Date 7–,7!'r- � Reinspection Fee $15. - Issue Fee $ 3-. .
Drivers' License or SS lc - 01 00009967-00009968 TOT 81.50
' 0065-46,rev.5/88 White - Building: Canary - Applicant; Pink -Accounting: Goldenrod - Assessor '
COyyN��S��TRUCTION AND PLANNING POO SPA
API4WjVALS Permit Date Inspector APPROVALS Permit Date Inspector
1. TIbmporary Electrical Service or Pole • 52. Pool & Equipment Location _- .
2. Soil Pipe-Undrgrnd. • ' 53. Steel Reinforcement
i
3. Electrical Conduit-Utility-Undrgrnd. 54. Forms
4: Electrical Conduit-Undrgrnd. 55. Electrical Bonding
5. Steel Reinforcement. _ 56. Rough Plumbing & Pressure Test -.
6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE i
- t
' 7. Footings 58. Electrical Conduit-Undrgrnd.
8. Foundation 59. Gas Pipe, 0 Undrgrnd.,Test
9. Water Pipe-Undrgrnd. 60. Backwash Lines,P-Trap, 0 Undrgrnd.
10. Structural Floor System 61. APPROVAL TO DECK
11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final
12. Sewer Cap,' ' 63. Heater & Vent-Final
13. Roof Drains 64. Plumbing System - Final
14. Rough Plumbing- 65. Electrical-Final
15. Rough Electrical-Conduit 66. Solar System-Final
16. Rough Electric Wiring 67. Fencing & Access Approval
'17. Rough Wiring Sign 68. APPROVED FOR PLASTERING I
18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
'19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
•20.. Rough Factory Fireplace APPROVALS Permit#
21. Ducts, in Structure 70. Underground Hydro
22. Ducts, Ventilating 71. Product Piping 0 Gas 0 Oil
23. Gas Pipe-Rough & Test 72. Underground Flush
24. Roof Framing 73. Undergrnd.Storage Tank 0 Gas 0 Oil
25. Roof Sheathing 74. Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical
27. Frame and Flashing 76. Dry Standpipe
28. Lathing.6...Siding 77. FIXED SYSTEM FINAL
29. Insulation 78. FIRE PREV. FINAL
30. Drywall Nailing i - HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat 79. FINAL INSPECTION
32. Electrical Power'Meter-Final 80. FOOD CERTIFICATE ISSUED I{ '// A
33. Final Electric Notes:Jo .'2 ar 3772661 / 411 P
• 34. Final Heating & Air Conditioning •j/y6�fi V� r- 12- 6 ./ J7I
�/
35. Final Gas Pipe-Test ! 11 �"
36. Hood or Canopy
37. Final Factory Fireplace
38. Final Plumbing
39. Water Service-Final
40. Gas Service-Final
41. Solar Domestic-Final
42. Backflow Preventer
t
43. Backf low Irrigation
44. Landscape Irrigation System
45. Sound Attenuation
46. Handicap Regulations ///��� . (
47. FINAL STRUCTURE & BUILDING y etp - - •
4R. Snecial Requirements Completed / 1
49. Electric Release to Edison ,
50. Gas Release to Southern California Gas Co .
51. CERTIFICATE OF OCCUPANCY •
No. Date ..
FEE RECF_II/FD
. L 17054
fry mAy17 1961
. ______
COSTA MESA BUILDING-SAFETY DEPARTMENT FINANCE DEPT.
P. 0. BOX 917 COSTA MESA. CALIFORNIA CITY OF COSTA MESA
For Applicant to Fill In Completely APPLICATION FOR PERMIT
TYPE OR PRINT
BUILDING
BUILDING 3 03-7 maili-,,,,., 44-e .
ADDRESS
COSTA MESA. CALIFORNIA For Office Use Only
I RECEIPT NO. I
OWNER Occidental Loan Company 77054
L..
MAIL RECEIVED SY I RECEIVED I DATE ISEMIER2
ADDRESS 2SE 901 Benedict Canyon Drive AP ..ti s
TEL CR.-6- BUIL
DING
CITY Beverly Hills NO. -_ . , ADDRESS 3059 ad 1 son Avenue
0 v't•J
ARCHITECT TEL. COSTA MESA. CALIFORNIA
OR ENGINEER --- NO.
--
--- FIRE
ADDRESS ZONE TYPE 1/ GROUP J 0-
CONTRACTOR Alfred A. Edelsohn APPROVED
BY DATE
ADDRESS 2901 Benedict Canyon Dr. ZONING
ZONE NO.OF ..-2 I USE OF NEW SA"(-Zia ha.
CITY n, v, n rl y T-I 1 1 l_S , CA "I -11
1 0 rri A 6__i I PLANS C BUILDING 14./ac..#04F, •
-.
IS-IrriL. 141355 TEL r.R.-
NO. Y 6-894o LEGAL
DESCRIPTION Lot # 27 TR-11607
SIZE I NO. OF 81.008. 0
OF LOT 623(100 NOW ON LOT A.P.NO. .
USE OF YARDS EVES
EXISTING BLDG —
APPROVED ALLOWED
SETBACK LINE FROM (CENTER LINE ST.)
CENTER or STREET cO I REAR YARD 311
FRONT Ar0 FT.
IN.
-
SIDE YARD I LEFT 5' I RIGHT 5' R.SIDE S.—FT. —
IN.
DESCRIPTION OF WORK
L.SIDE .5"-- FT. ,__--.
IN.
NEW I X II ALTERATION I II ADDITION I REAR 3/ FT. .--7 IN.
REPAIR I 1MOVING I II DEMOLISH I APPROVED ecie
BY A...041) DATE
BUILDING..
.
ILD I N C. 2 x119 NO. OF
Rooms 7 STORIES 1
EXTERIOR WALLROOF
COVERING 11T ac co I COVERING WO Od & Rock
UOF BUILDING AND tEl ?IEDtlaitsvaragptGar.
A-9 /C.-3?
y?
....
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUAr9 ,_is FOR THE
AND STATE THAT THE ABOVE MI CORRECT AND AGREE TO CON. PURPOSE OF ESTABLISHING A PERMIT FEE ONLY.
PLY WITH ALL CI. ORDINANCES AN STAT WE REG TIN(
BUILDING CONE I CTIO VALUATION
9/ —
' PERMIT FEE $SIGNATURE •-
PERM ITTEP i s 21 ,0214.00 N
PLAN CHECK S
S
AUTHORIZED A• NT
TOTAL FEE $ e/e.5-0 „.6'