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Home My WebLink About3129 LINCOLN WAY - Building Permits ' ' CITY OF COSTA MESA 4 BUILDING DIVISION °'j�i",,� PERMIT NUMBER F ( DEVELOPMENT SERVICES DEPARTMENT P05-00375 i. illocit PERMIT J41. (714)754-5273 • Fax(714)754-4856 • www.ci,costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 3129 LINCOLN WY Status: ISSUED Suite No Applied: 05/13/2005 Issued: 05/18/2005 Vicinity: Parcel Nunmber: 14165242 ,i _ - - - - ISSUED BY: I.1 /Applicant: SZABO, KEVIN/1" - • Address: '' �� , ' Phone: - • Zip: , C _ _ �C ,� Owner: AGUNOD, ARCADIO H TR ` Address 3129 LINCOLN WAY - Phone: - • COSTA MESA,CA Zip: 92626 Contractor: ' COAST ROOTER PLUMBING-HTO &NC . - .Address: 17390 MT CLIFFWOOD .. p Phone: (714)241-1414 • FOUNTAIN VALLEY Zip: 92708 , License: 529127 SCOPE OF PERMIT , - WATER HEATER CHANGE OUT(SAME LOCATION). - FEE SUMMARY AMT OTY' -AMT QTY AMT QTY ISSUE FEE , $23.50 Laundry Tub/Washer $0.00 ' 0 Sump Pump ' , $0.00 0 Backflow irrigation , $0.00 0 ' Landscape Irrigation -$0.00 0 Swimming Pool $0.00 0 Backflow Preventer , ' $0.00 0 P-Trap $0.00 0 Trap Primer - $0.00 0 Bathtub' . $0.00 0 Pressure Regulator ;,� , $0.00 0 Urinal ,$0.00 ' 0 Clarifier System $0.00 0 Process Piping(per 10 ft)`-,$0.00 0 Vacuum BrkrBkflow(1-4) $0.00 0 Connect(Ice,Soda,etc) $0,00' 0 Receptors ' $0.00 ..0 Vacuum-Brkr Bkflow(5+) $0.00 0 Dental Units , $0.00 0 Septic'Tank ',''<, '$0.00 ';'0' Wash Basin $0.00 0 Dishwasher . . ' $0.00',\' 0. -/ Sewer Cap for Demo=, ." $0.00.' -0 , ' Wash Basin Set, $0.00 0 Drain, Floor - $0.00 `'0 Sewer Connect -` - `$0.00 0 Waste and Vent System' $0.00 0 Drain, Rainwater i $0.00, 0; Sewer Private Line - f'' $0.00, '0-_ _ Water Closet(Toilet) , . $0.00 0 Drain, Roof ' $0.00 % 0 -- 1. .Shower - •. ' $0.00 0, Water Heater/vent' " $12.30 1 Drinking Fountain . $0:00 0 , Sink,bar - ' $0.00 - 0- - Water Piping(Inst or Rep.) $0.00 0 Expansion Tank N :$0.00 _' 0 i. -; Sink,commercial-- ., . $0:00 0- - \Water Re-pipe $0.00 0 Gas Earthquake Valve c, $0.00 " ,I,0 ' '-^''Sink,Floor - -$0.00 0, Water Service ,/� $0.00 0 Gas(1-4 outlets) $0.00\ 0`. ` 'Sink,kitchen_ ,$0.000;` , Water Softener $0.00 0 Gas(Over 4 outlets) $0.000 ' 1 'Sink,ser/icehnop ' $0.00 -0 `. : ,� OTHER .7 $0.00 Gas Repipe $0.00''-,0:4 -Spa(private) $0.00 0 . -VIOLATION $0.00 Gas Service $0.00 0 -.., . Spa(public) ' - .. $0:00 0. . ' PLAN CHECK $0.00 Interceptors(Grease,Oil) $0.00 0 - - _ " - REINSPECTION $0.00 0 Interceptors(Sand Auto) $0.00 0 - /' 2 - TOTAL CALCULATED FEES: $35.80 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: 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 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 2446-46(WOO) DECLARATIONS '-." WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: _ t ; 0 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. 1 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 parrot Is Issued. My workers'cnom .pfensa'ti`on Insurance carrier and policy number are: f 7 •tV —ZOO L' ardor: DLv�-I/�+ I +4(J . Policy Number: V4 '/�{/' (This section need not be completed if the permit is valued et one hundred dollars($100)or less.) ❑ I certify that In the performance of the work.for w ich this permit is issued,I shall not employ any person In any manner seas to become subject to the workers-' compensation laws ofCalifomia, nd gree the if I sh Id become subject to the workers'compensation provisions of Secti n 3700 of the Labor Code,I shall forthwith comply with these provisions. c f I / 9 5 Applicant Signature: / V 7 Date: EE WARNING:FAILURE TO SECURE WORKE PEN ON COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTI S AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE(S100.000).IN ADDITION TO THE T OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of C :pier 9( • mencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect.Lic.II ' Class A Contractors Signature: l�iff/A Date: 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: Lender's 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 clvil penalty of not more than five hundred dollars($500).): ❑ I,as owner of the property,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 apply to an owner of properly 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. 0 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,es 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: 1 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 Califomia 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 standardtemperature 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 ❑Ne (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 Califomia 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 epermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Li Yes IIN No (Section 65850.2 of the California Government Cale requires that the requested information be furnished on applications for non-residential building permits). _____ _._..._._. n_ ..._____ ___.._ _..___ — 6 Will any part of the facility to be constructed under this permit be within 10000 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 II 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 and 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-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signatur Of Legal Owner(s) Dela cA n uthorized Applicant / Date 1 COOE I, INSPECTION-MC ' " - • - OATS - 'RITIRAI5 ' CODE IBSPECTION TYPE ' ' - RhJ ROMA 1616 Fixed System Final Fire Prevention ' . 206" Final Mechanical . ' • 1266 Pool Spa Final 208 Final Plumbing 6-2--Os 13 NI 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 • PROJECT ADDRESS: 3129 LINCOLN WY UNIT: CITY OF COSTA MESA — BUILDING PERMIT 4PERM NO: B 071072 'DOER'S NAME: AGUNOD, ARCAD I O H FLOOD: X 47 ADDRESS: AGUNOD AVELINA L PERMIT NO: B 071072 PLAN CHECK NO: N GOVT: N SUPP : N 3129 LINCOLN WAY COSTA MESA, CA 92626 CONSTRUCTION TYPE; 5—N PERMIT TYPE; STA PURPOSE: ALT ARCH/ENGINEER: REG.No.: JOB DESCRIPTION : CHANGE—OUT 4 WINDOWS "SAME SIZE" SQ FT; 6, 000 ADDRESS: UNIT: CLAIM VALUE; 6, 000 . 00 CALC—VALUE: 6, 000 . 00 GROUP OCC; R-3 / PERMITTEE: AMRE REMODELING ( 714 ) 937-0101 ADDRESS: 3042 S . ORANGE COMMENTS; SMOKE DETECTORS REQUIRED PER THE 1991 EDITION OF THE UBC. .6 SANTA ANA CA 92707 *** .r+a**,¢*trim***r,r•�E*******+fir fir***+r�F****************** ******�e,F*+r*4******44.c**** LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section Z ONING REQUIREMENTS 7000)of Division 3 of the Business and Professions Code.and my license is in lull force and eel. CITYLIC.: 049126 STATELIC.:473042 CLASS: B , XP : 10/95 S E T B A C K S Date:_,2—IO -9C Signature:— .. __ MAIN BUILDING ACCESSORY BUILDING WORKERS'COMPENSATION DECLARATION: I hereby affirm that I have a Mika consent to self-insure or a certificate of Workers' FRNT: FT IN REAP.; FT IN FRNT: FT IN REAR; FT IN Compensation Insurance.or a certified copy thereof(Section 3800.Lab.C). LEFT: FT IN RGHT; FT IN LEFT; FT IN RGHT: FT IN POLICY NO.: WC1O2S2O234 EXP.DATE: 11 /01 /95 COMPANY: TRANSPORTATION PARKING REQ: PROV: PARCEL: 14165242 ZNE ; REF NO: NCertified copy is hereby furnished- El Certified copy is fir, ,th the city Building Division. / PLANNING NOTES> . date: pi—N--QC _ Applicant: — S! �OA EXEMPTION FROM WORKERS'COMPENSATION DECLARATION: (Thi section need not be come. it the permit i for one hundred(5100)or less). DEVELOPMENT SERVICES REQUIREMENTS I certify that in the performance of the work for which this permit is issued.I shall not e--'i oy any person in any manner so as to become subject to the Workers'Compensation Laws of California. ZONING APPROVED BY DATE: • Date: Signature: NOTICE:If.after making this declaration.you should become subject to the Workers'Compensation provisions of the Labor BUILDING APPROVED BY ; DATE: Code.you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for APPLICATION ISSUED BY: DATE: 2_j't o q r which this permit is issued(Section 3097.Civ.C). ********************************************* *********************y�rt�--*1. •****** LENDER: ******************************************************************************* ADDRESS: LEGALIZATION:N F E E SUMMARY STRUCTURAL SEGMENT:Y OWNER BUILDER DECLARATION: I hereby affirm that l am exempt from the Contractors'State License Law for the following reason BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING (Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct,alter,improve,demolish,or PERMIT 81 . 00 60 repair any structure,prior to its issuance.also requires the applicant for such permit to fife a signed statement that he/she is licensed pursuant to the provisions of Contractors'State License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business • SMIP/NON—RES and Professions Code)or that he/she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by PLAN any applicant for a permit subjects the applicant to a civil penalty al not more than five hundred dollars(S500). ISSUE FEE I. as owner of the property or my emMoyees with wages as their scompensation, will do the work, and the BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE ❑ sole compensation, structure is not intended or offered for sate(Section 7044,Business and Professional Code: The Contractors'State License Law TOTALS————> 81 . 60 0 . 00 0 . 00 81 . 60 81 . 60 , 00 does not apply to an owner of a property who builds or improves thereon.and who does such work himselUherself or through his or her own employees,provided that such improvements are not intended or offered for sale.II,however the building or 7 ——>pepuofa improvement sold withinBLDG PMTO PLUMBING ELECTRICMECHANICFIRESMIP/TOT one year of completion,the owner will the burden of proving he/she did not build or improve REVENUEODDO /S forthepurpose GRADING PLAN—CHECK I,as owner of the property.am exclusively contracting with licensed contractors to construct the project(Section 7044,Business 81 . 00 . 60 ❑ and Professions Code: The Contractors'Slate License Law does not apply to an owner of property who builds or improves thereon and whocontracts for such Protects with acentractor(s)licence pursuant to the Contractors'State License Law).l am aware *****************************************************.*****************.********* that proof of their Worker's Compensation insurance should be provided to me. INDIVIDUAL F E E BREAKDOWN o I am exempt under Section: B.&P.C. for this reason: TYPE QTY DESCRIPTIO N UNIT COST TOTAL COST Date: Owner: SFR 6000 ALTER BY VALUE RESIDENTIAL NOZONE 1 . 006, 000 . 00 I do hereby certify that I am aware of and understand the requirements of California Health and Safety Code Sections 25505.25533.and END OF FEES 25534 and that I or any future building occupant will/will not(circle one)need to comply with said state codes and the requirements for a permit for construction or modification from the Air Ouabty Management District.Residential construction applications are exempt from these provisions. Date: Applicant: I hereby certify that I have read this application and state that the above information is correct.I agre- o comply with all city and county ordinances and state laws relating to building construction and hereby authorize representatives of this c io enter upon the above-mentioned / property for inspection purposes. J �_s 41 �� 01 00176455-00176456 TOT 21.aG Date. Signature: / ." DATE: 02/30,'4$ TIME. `l1 Dover's License or Social Security.: 03:33 1641-46 Wrote—Building:Green—Code Enforcement Canary—Applicant:Pink—Revenue:Goldenrod—Assessor CONSTRUCTION AND PLANNING POOL PA _ APPROVALS Permit# Date Inspector APPROVALS Permit# Date Inspector 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. 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 r 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 18. Rough Electrical-I 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& Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREY. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes: (1-.2 Y-'7 - 6t'Q,cP . i et -e 34. Final Heating& Air Conditioning crff vN.4/7- Pitt _ caz 35. Final Gas Pipe-Test /'c 'C� 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 43. Backflow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE& BUILDING 7_2:2_,1%, 6 eLL_ 48. FINAL PLANNING 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date 18766 FE RECEIVED COSTA MESA BUILDING-SAFETY DEPARTMENT FEB 1 1963 P. O. BOX 317 COSTA MESA. CALIFORNIA FINANCE DEPT. For Applicant to Fill In Completely APPLICA$IONC OROPERM(TSA TYPE OR PRINT BUILDING BUILDING ADDRESS 3129 Lthco2n Way COSTA MESA. CALIFORNIA For Office Use Only �/TT � � J I( RECEIPT NO. Py[T��ry O//_ OWNER 1/rW".e/7}ai /OOII COm/10/1y 1 I % / TE MAIL '1 {/ n I / O RECEIVED// DATE RECEIVED {1 DATE ISSUED ADDRESS 5 Rojihoa Bi V� /L� ('LL 1 J 1`�6Y FEB I_ 8 1913 TELILDING CITY ( la !1.PAG N054( 5 5 ADDRESS Coy JY!]O O ADDRESS ARCHITECT TEL. COSTA MESA. CALIFORNIA OR ENGINEER NO. , / o �/ ZONE TYPE �✓ GROUPS/? it / FIRE ADDRESS ,/ I ^ ) / (//' CONTRACTOR A1�.ed A. aided n. APPROVED DATE ADDRESS 2907 Ben ed.C.f Cayon Ili in ZONING I _ ZONE I NO.OF I USE OF NEWS... Z 'Z..,/Ry CITY I '1� / _ /,• _• / ( / . 1 PLANA BUILDING !vI u'hL9si 0-- ST ATE STATE //' TEL. ``D LeGAL T ��7 L.// p LIC.NO. 141,3 NO.U48940 DESCRIPTION L�>� J rPCIt /I • v 06, SIZE NO. OP BLDG'S. OF LOT . NOW ON LOT A. P.NO. ` USE OF YARDS EVES EXISTING BLDG. APPROVED ALLOWED SETBACK LINE FROM 51 26 I (CENTER LINE ST.) CENTER OP STREET REAR YARD {{JJ FRONT 6/ FT. J IN. SIDE YARD I LEFT 5 I RIGHT 5 R.SIDE - FT. IN. DESCRIPTION OF WORK L.SIDE S- FT. N. NEW I X I ALTERATION I I ADDITION REAR a FT. IN. II MOVING I II DEMOLISH I APPROVgO1l ��y DATE i'1 REPAIR 6 1 `t:-' ,,,/// SIZENO. OF BUILDING 52 X 49 ROOMS STORIES 7 y J EXTERIOR WALL(' / ROOF �1 ) pp Poch '� COVERING S.taCCO COVERIN god (} nock USE-OF BUILDING ANO ORK TO B P FORMED 7-Fain . .ed. W/a#.tac t get/tag e. J I_ na- &ViGiri�J y1/y°, I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS PPLICATION THE AMOUNT SHOWN UNDER VALUATIO„U'FOR THE AND STATE THAT THE ABOVE IS CORRECT AND AG-EE TO COM. PLY WITH ALL CITY O-•INANCES AND STATE LAWS REG TING PURPOSE OP ESTABLISHING A PERMIT FEE ONLY. BUILDING CONS -j'ON. VALUATION U SIGNATURE iapr. PERMIT FEE " 44,� PERMITTEE -- !�,- p a $ ,//I / nO PLAN CHECK $ 20. C AUTHORIZED AGEN 1 "`^O/ /9y/ '' 0-0 ai//(! 0 _ - .. TOTAL FEE $ � c