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HomeMy WebLinkAbout1989 KORNAT DR - Building Permits (..:D o pyr CITY OF COSTA MESA BUILDING DIVISION IAl 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 Scles0;wto(fr. PERMIT NUMBER: BX10-00232 PERMIT TYPE B_MISC STATUS: FINALED APN: 13944205 DATE ISSUED: 10/20/2010 Zoning: R1, ISSUED BY: RMD JOB ADDRESS: 1989 KORNAT DR CM Suite/Unit: Vicinity: REAR YARD Primary Occ: 32 Const Type :?? SQ.FT: 168 Valuation: $3,000.00 SCOPE OF WORK: CONSTRUCTION OF A 168 SF DETACHED PATIO COVER WITH 1 LIGHT FIXT LOCATED AT REAR YARD. REFER TO MM-10-16 FOR REDUCED SETBACK ON THE REAR OWNER: CERNOK BRIAN AND KATHERINE B Address:: 1989 KORNAT DR Unit City/State: COSTA MESA,CA Zip Code: 92626 Phone: 714-585-8166 APPLICANT: CARR,WARNER Address: Unit: City/State: Zip Code: Phone: 949-689-5540 CONTRACTOR: HOME ENHANCEMENT SPECIALIST INC License No. 737089 Address: 23381 VIA LINDA Unit: UNIT B City/State: MISSION VIEJO, CA Zip Code: 92691 Phone 949-689-5540 Cell: ARCHITECT: License No. Phone ENGINEER: UNIVERSAL ENGINEERING License No. C74572 Phone 949-788-0424 FEE SUMMARY Building Plan Check: $54.11 Building Permit: $83.25 Electrical Permit: $24.60 SMIP Residential $0.50 SMIP Commercial $0.00 Bldg Std Admin Fund $1.00 TOTAL FEES $163.46 HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/1812010 -PER CMMC Sec. 13-279 Monday thru Friday-7:00 am thru 7:00 pm. Saturdays-9:00 am thru 6:00 pm. Prohibited all hours-Sundays and the following Federal Holidays: New Years Day,Memorial Day, Independence Day,Labor Day,Thanksgiving Day and Christmas Day 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. CODEC. INSPECTION TYPE DATE INnnALs CODEC INSPECTION TYPE DATE INi111ALS 1618 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing / 200 Final Re-Roof 210 Final Electrical l( II-1 &-I O )----r 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 Ib 1 W \VC:11 f h WORKERSLCOMEENSATION DECLARATION: Owner ID verified by drivers license. 0 Yes ❑ No I hereby affirm under penalty of perjury one of the following declarations: Driver's License No. Expires: ❑ I have and will maintain a certificate of consent to self-Insure for workers' _„Verification of Ownership by(type of document,i.e.-property tax bill or deed): compensation, as provided for by section 3700 of the Labor Cole. for the performance of the work for which this permit is issued. • • ❑ I have and will maintain workers'compensation insurance, as required by DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: 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 ❑ 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 Carrier: or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp (This seUbn need not be completed if the permit Is valued at one hundred dollars($100)or less.) 2,Art 2Sec.341,Title 6,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 Applicant's Signature Dale the Labor Code,I shall forthwith comply with these provisions. 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? 0 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? 0 Yes 0 No Lit.# 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 Contractors 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 ❑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? ❑Yes 0 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 ❑ No issuance,also requires the applicant for such permit to file a signed statement (Section 65850.2 of the Califomia Government 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 0 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 hundred dollars($500).): of the California Health and Safety Code). ❑ 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 ❑No thereon,and who does such work himself or herself or through his or her own 8. (If"yes",attach certificate of compliance from the appropriate air pollution employees, provided that such improvements are not intended or offered for 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 property, am EXCLUSIVELY CONTRACTING WITH city ordinances regarding Hazardous Materials and Emissions. LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code: The contractors License Law does,not apply to an owner of Signature Date 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 ❑ I 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 property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature of Legal Owner(s) Date Signature Dale 3057-46(3/071 Ana/or Authorized Appiicanl Date CITY OF COSTA MESA ©O RV 0501tiss., BUILDING DIVISION ', 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us �. 8 FOR INSPECTIONS CALL: (714)754-5626 4`egur.ii. PERMIT NUMBER: P10-00135 PERMIT TYPE PLUM STATUS: FINALED APN: 13944205 DATE ISSUED: 10/04/2010 • ISSUED BY: RMD JOB ADDRESS: 1989 KORNAT DR CM Suite/Unit: Vicinity: REAR OF YARD SCOPE OF WORK: PLUMBING PERMIT FOR FUTURE BBQ AND FIRE PIT AREA LOCATED AT REAR YARD OF A SFD. REF#: E10-00232 OWNER: CERNOK BRIAN AND KATHERINE B Address: 1989 KORNAT DR PHONE: 714-585-8166 City/State/Zip: COSTA MESA,CA APPLICANT: CARR,WILLIAM Address: PHONE: 949-689-5540 City/State/zZip: CONTRACTOR: •HOME ENHANCEMENT SPECIALIST INC License No. 737089 Address: 23381 VIA LINDA UNIT B PHONE: 949-689-5540 City/State: MISSION VIEJO,CA ZipCode: 92691 CELL: ARCHITECT: License No. PHONE: ENGINEER: License No. PHONE: • • PLUMBING PERMIT FEE SUMMARY PLAN CHECK FEE: $0.00 PERMIT FEE: $49.25 TOTAL FEES: $49.25 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord. No.92-28, § 1,'12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE#. INSPECTION TYPE DATE INTITIALS CODE# INSPECTION TYPE DATE INTITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical X57 1266 Pool$pa Final 208 Final Plumbing x //—I(o —1 D MP39-- 200 Final Re-Roof 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 CI\ fC, WORKERS'COMPENSATIONJDECLARATION: Owner ID verified by drivers license. 0 Yes 0 No I herebyyaffirm unde;penaltyof,perjury one of the following declarations: Driver's License No. Expires: ❑ I have and will maintain a certificate of consent to self-Insure for workers' Verification of Ownership by(type of document,i.e.-property tax bill or deed): 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 DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: 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 ❑ 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 Carrier: or dismantling thereof,will be more than thirty-six(36)feet high. (Chap.3.2,Grp (This section need not be completed if the permit is valued at one hundred dollars($100)or less.) 2,Art 2,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 Applicant's Signature Date the Labor Code,I shall forthwith comply with these provisions. 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 ❑ 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 tt (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)? ❑Yes ❑ 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 Date 4. If an RMPP is presently required, has Section 25534 of the California OWNER-BUILDER DECLARATIONS: Health and Safety Code been fully complied with? ❑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 hundred dollars($500).): of the California Health and Safety Code). ❑ 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 8 (If"yes", attach certificate of compliance from the appropriate air pollution employees, provided that such improvements are not intended or offered for 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 property, am EXCLUSIVELY CONTRACTING WITH city ordinances regarding Hazardous Materials and Emissions. LICENSED CONTRACTORS to construct the project(Sec.7044. Business and Professions Code: The contractors License Law does not apply to an owner of Signature Date 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 ❑ I 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 property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature or Legal Owner(s) Date Signature Date 3057-46(3/07) And/or Authorized Applicant Date OWNER SAMAR CONST.CO.. _ DATE NOV 4 19R3 JOB ADDRESS 1989 Kornat Drive BUILDING PERMIT NO. 20852 GENERAL CONTRACTOR Samar Conat.Co. VALUE $19446.00 AP No. LOT 115 TRACT 4341 FIRE ZONE DESCRIPTION OF WORK Res.W/att.Gar. INSPECTIONS "nature DATE GROUP I & J TYPE V ZONE R1 Soil • X-Ki 7�-3- PERMITS ISSUED Gas dd� SUBCONTRACTOR DATE NUMBER Water T -a /A-/O-L3 Rough Corn. Refrig. 0 Air Cond. ❑ Rough Heating >n /-R_. _ •_ _ by 6 1964 —21±744 Rough Plumbing - _ _ ///9.4.7 5' 9 g-2 Miscellaneous i'� Prop. Swr. Line 0 House Con. 0 St. SWr. 0 : 4- - C Ltil . c llA - • 3�-(M to .- /?-' Sprinkling System Construction Pole LI I Underground ❑ Power 0 n Rough Wiring r7? �^L9-G4-r ��X�=s-b (-.e..• JAN 2 1 19ba � 1 P 2.-(, TrenchesP--- Forms Or--Steel Reinf. Jg---- /z-L/— < Floor System tG /� �F— 3 Bond Beam 0 Steel Reinforce 0 �!`— Sheathing ,., Frame and Flashing /it 7--el_Cre( f Lathing—In gip- Out E- /CS-W ;2.-r-4-ry _ Plaster, brown coat e441 3-19—Lci Refrig. 0 Air Con. 0 Final Heating, Final - 9 7 9 Plumbing Fixtures, al Final Gas Test es, S._ 'Mr Electric Fixtures, Final r.2.8_Fc/ Building, Final ! ty.z 4 ;44' _ I OCCUPANCY ✓ / J Form 33U4-5M-3-63-5-B P 20e1 FEE RECEIVED .;I 1 7 1963 COSTA MESA BUILDING-SAFETY DEPARTMENT • FINANCE DEPT. P.O.BOX 917 COSTA MESA,CALIFORNIA / CITY OF COSTA For Applicant to Fill In Completely APPLICATION FOR P Tr. 4341 TYPE OR PRINT Lot 115 BUILDING BUDING For Office Use Only ADDRESS 1989 Kornat Drive RECEIPT NO. 2Q COSTA MESA. CALIFORNIA / L// LL RECEIVED BY DATE RECEII ED NOVDATE ISSUED OWNER Samar Construction Co. £' /4//4 49 N 4 1033 MAIL BUILDING ADDRESS 1653 Minorca Drive. ADDRESS FIRE TEL VeCITY Costa Mesa NO. ICI 90395 ZONE TYPE GROUP k).tir AP ARCHITECT TEL. BYPROVHD DATE OR ENGINEER F G Knitenhnrh NO. 547-8046 ADDRESS1823 E. 17th St. Santa Ana ZONING ZONE NO.OP USE OF NEW Rl I PLANS2 I BUILDING S/res.w/att. CONTRACTOR Same as Owner pp DESCRIPTION Lot 115., Tr. '4i. ADDRESS CITY A.P.NO. NOTE: NO EAVE OVERHANG SHALL BE LESS THAN STATE 197838 TEL 90•TO SIDE B REAR P.L. LIC.NO. NO. SIZE EAVES OF LOT 69 x 100 I HOW ON LOTS O ALLOWED (U.B.C.REQUIREMENT) YARDS APPROVED YARDS APPROVED USE OF MAIN BUILDING ACCESSORY BUILDING EXISTING BLDG. --' (FROM C/L STREET) SETBACK LINE FROMI FRONT CO FT. FT. CENTER OF STREET 50REAR YARD 27 // SIDE YARD LEFT 5' - I 'RIGHT 6 R.SIDE 6 P'r. Fr. DESCRIPTION OF WORK L.SIDE SFT. Fr. I7 ,( NEW X ALTERATION _ ADDITION REAR d FT./0 FT. DISTANCE BET. BET.MAIN REPAIR MOVING DEMOLISH MAIN BLOCS. ACCESS.BLDGS. BUILDING. NO.OF VAR.# DATE SIZE i .714 sq.ft. ROOMS 7 STORIES 1 C.U.P.# APPROVED EXTERIOR WAL Wood 81 ROOF Cx Qke & APPROVE {��� (� /'7 COVERING StUCCO 'COVERING Oringle BY ;AJ Z, 1 DATE /0—/ Y—b y USE OF BUILDING AND WORK TO BE PERFORMED Single family residence and attached ig garage. p Plan 41 C —1/72i so.Fr.c9Vfif%�/O/33/ " / I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM. PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. O PLY WITH ALL CITY ORLON ECHE AND STATE LAWS REGULATING VALUATIONai �� - DI' BUILDING CONSTRUCTION. PERMIT FEE 5N SIGNATURE OF L///� /' m PERMITTEE 1/14'I'r// $ /// ���-, C ��v0 Z AUTHORIZED AGE $ 2j /�L� , TOTAL FEE / .J