HomeMy WebLinkAbout106 THE MASTERS CIR - Building Permits r
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CITY OF COSTA MESA -
Ca)111 BUILDING DIVISION
DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
PERMIT
1B04-00849
-
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
BUILDING PERMIT
Job Address: 106 THE MASTERS CI Status: ISSUED
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Suite: Applied: 05/06/2004
Vicinity: RESIDENCE AND ATTACHED GARAGE Issued: 05/06/2004
Parcel Number: 11939102 Zoning:
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Applicant: FERGUSON, LEW ISSUED BY: ,„„e#,,.„,,,_!
Address: 4091 E LA PALMA
SUITE D Phone: (714)630-5543
ANAHEIM,CA Zip: 92807
Owner: SHAFFER, GEORGE R AND EVELYN C
Address 106 THE MASTER CIR
Phone:
COSTA MESA,CA Zip: 926274640
Contractor: MC CORMACK ROOFING
Address: 4091 E LA PALMA
SUITE D Phone: (714)630-5543
ANAHEIM,CA
Zip: 92807 License: 643700
Arch : Eng:
Address: Address:
Phone: Phone:
Zip: License: License:
SCOPE OF PERMIT
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REROOF RESIDENCE AND ATTACHED GARAGE:T/O EXISTING TILE ROOF, REPAIR/REPLACE SHTG AS NEEDED,BATTEN, 1 LAYER 30#
FELT,APPLY"DURA-LOC METAL TILES."ICBO#4970; 1.3 PSF; 17 SQUARES ON PITCHED ROOF.
FLAT ROOF 11 SQUARES: B.U.R.
FEE SUMMARY
Plan Check: $0.00 Calc Valuation: $8,500.00
Permit: $167.25 Claim Valuation: . $8,500.00
SMIP Res: $0.00
SMIP Corn: $1.78
Other: $0.00
Inspection: $0.00
Total: $169.03 •
PLANNING &ZONING
SETBACKS
MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0
ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0
PARKING Existing: 0 Required: 0 Proposed: 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)
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(6/00)
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
O 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
rk for which this permit is issued.
I 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 permit is issued.
My workers' mpey^+ation Insurance carrier and policy number are: p/�
Carrier: r_s Policy Number: [..C..7 3 /�5 7 A o tQ
(This section need not be completed it the permit is valued at one hundred dollars($100)or less.)
❑ I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of Calif ia,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these pro isi ,
Applicant Signature: y.w.,.t�. // Date: 0,0,6701/
6/O
WARNING:FAILURE TO SECU WORKERS'COMPENSATION rxEFRA IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES Up TO ONE HUNDRED
THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed der provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full
force and effect.LIG.* Cr, Class It e 315
Contractor's Signatur : Date: C9 3-7c, O V
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).
Lender's Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that 1 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 civil penalty of not more than five hundred dollars($500).):
❑ I,es owner of the properly,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.It,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.). •
O 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 property 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 driver's license. 0 Yes ❑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,as noted above, unless such person hes 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? ❑Yes ❑No
(Section 25505 of the California 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 standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes ❑No
(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 California Health and Safety Code been fully complied with? ❑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 a kermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes 0 No
(If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code).
7 If 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 ❑No
.i.ce o.compliance
... ...rom the appropriate
ar. control
8 (If"yes",attach certificate of clafrom the appropriate air pollution cofficer).
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 Le.: Owner(s) DatOOP 20od r
And/Or Authorized A.,.21. t Dale
CODE# INSPECTION TYPE FAL MI1,911 CODE( INSPECTION TYPE RATE IfTTITIALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final /���,�y/ 208 Final Plumbing
(
200 Final Re-Roof / �"r/]-c y r 7i3 210 Final Electrical
201 Final Bloc 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
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\--JOB- tr 10 40.7 Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations.
. PERMIT-NO. ��) TRACT NO. LOT NO. UNIT NO. 2204 11 /14/84 1 5.50 ' IL
.., CITY OF COSTA MESA CONSTRUCTION PERMIT RM,
Project Address 106 THE MASTERS CIRCLE, COSTA MESA
Applicant's Mailing Address 1441 SO. ANAHFIM BLVD, NAA IM 31T OF CONSTRUCTION ® NEW ® ADD LI ALTERATION U REPAIR
CONVERSION ❑ DEMOLISH ❑ OT A.P.# Zone
Owner's Name WII I TAM C WARRFN Phon640-1 92 { SALLAf10N OF AIR COND.
DESCRIPTION OF WORK/USE OF BLDG.
Address 105 THF MASTFRS CT 12C1 F COSTA MF SA 99627 REPLACE FURNACE. RESIDENTIAL/HOME S Main Building: Accessory Building:
Arch/Eng. ' License No. TYPE OF PERMIT ❑ GRADING FOUNDATION❑ I E 0
�J I- ❑ STRUCTURAL Front
1f) • C TENANT uy ELECTRICAL ❑ PLUMBING El MECHANICAL B N
Address -_ _ - A Rear I
I Contractor's NampKINNEY AIR CONDITInNINI3'hone772-1441 -.PROJECT
OTHER C Right . - N
�'-' Address(mailing)11+41 SQ ANAHEIM 31 Vnl ANAHF TM' AgX$ 92887OJECT DESCRIPTION SQ. FT. 176R OCCUPANCY—SINGLE_
I CONSTRUCTION TYPE VALUATION $ 3605.00 $ Left G
----. City License No. 005-21$ ZONE GRADING CU.YDS. ACRESR
LICENSED CONTRACTOR DECLARATION Ping. Ref. 4 Parking Req./Provided E
I hereby affirm that I am licensed under provisions of Charter 9 (commencing Remarks: Planning Notes: M
with section 7000) of Division 3 of the Business and Professions Code, and
my license is in fr6orce and effe T
License Class LL 'cense No. 41975$ S.
Date ' 11-9-84 Signatur - PLUMBING FEES
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WORKERS'COMPENSATION DqElgqsgvvIOO�(�!t R rnknTT PNBarShowers Tma Sink ELECTRICAL FEES
hereby affirm that I have a certifi'txate Os dn{eh4 to 3€IY'ilMitr!tiYd'c2Yttticate
,f Workers' Compensation Insurance, or a certified copy thereof (Section _
Backflow Preventer - -Service Sink
3800, Lab. �.1 9770425 INA Automatic Washer Transformer 0 15-50 KW
Policy No. 1— Company Backflow Irrigation Sewer Cap0 50+ KW
iCertified copy is hereby furnished. • Construction Pole Sub.
Certified copy is filed with the city Building •i 's'.n. t Bathtubs Sewer Connection - Cooking Unit Meter ❑up to 100 amps
Date ^ Applican
'•
I. ,�EXEI —K OM WORKERS'C• - I 0 ItATION ' Clarifiers Solar Collectors Dishwasher Meter Dover 100 amps
(This section need not be completed If the permit is for one hundred ($100) or .
less). Dishwasher Solar Piping Dryers ❑Gas ❑Electric Sub Panel
I certify that in the performance of the work for which this permit is issued, I
shall not employ any person in any manner so as to become subject to the Drinking Fountains Solar Tank Fan 1 Motors❑0-1 HP K11/2-6 1.50
Workers' Compensation Laws of California. I
32
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Date Signature - Floor Drains Swimming Pool w/Spa F.A.U. Inc.Solar ❑9-15 HP 016-15+
NOTICE: If,after making this declaration,you should become subject to the
Workers' Compensation provisions of the Labor Code, you must forthwith Floor Sinks - - Urinal - • Fixtures
comply with such provisions or this permit shall be deemed revoked. Microwave -
CONSTRUCTION LENDING AGENCY • Gas Service Outlets Water Closet - - Device Boxes
I hereby affirm that there is a construction lending agency for the performance - Pole Light
of the work for which this permit is issued (Section 3097 Civ. C.) Interceptors Water Heater Outlets
Lender's Name Range
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Lender's Address Kitchen Sink Water Service Switches Sign
OWNER BUILDER DECLARATION -
I hereby affirm that I am exempt from the Contractor's License Law for the Lavatories - - Garbage Disposal
following reason (Section 7031.5 Business and Professional Code: Any city or 9 P 'Standing Sections
county which requires a permit to construct,alter,improve,demolish or repair P—Trap _ Generator ❑0-5 KW ❑5-15 KW Trash Compactor
any structure, prior to its issuance, also requires the applicant for such permit -- --_ . - P '
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 - ,
herefrom and the basis for the alleged exemption. Any violation of Section
' /031.5 by any applicant for a permit subjects the applicant to a civil
malty of not more than five hundred dollars ($500).
U I, as owner of the property or my employees with wages as their sole Reinspection Fee I $15 Issue Fee $ 3
compensation, will do the work,and the structure is not intended or offered - Reinspection Fee $15 Issue Fee • $ 3
for sale (Section 7044, Business and Professional Code: The Contractor's MECHANICAL FEES
License Law does not apply to an owner of a property who builds or improves l
thereon, and who does such work himself/herself or through his or her own - DEVELOPMENT SERVICES REQUIREMENTS:
employees, provided that such improvements are not intended or offered for Boiler Hood or Type I ❑
sale. If, however, the building or improvement is sold within one year of com- Canopy Type II 0 Zoning Approved By Date
pletion, the owner will have the burden of proving he/she did not build or im- Duct- Under Ground Building Approved ByDate
move for the purpose of sale). •
O I, as owner of the property, am exclusively contracting with licensed con- Duct-Structural Refrigeration System 36M Application Issued By • Dat: al
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 1 X70-100,000 BTU 0100,000 BTU 4.00 -SUMMARY OF FEES
builds or improves thereon, and who contracts for such projects 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 BUILDING PERMIT $ SMIP - $
proof of their Worker's Compensation insurance should be provided to me. PLAN CHECK $ PERMIT
0 I am exempt under Section B. 8. P.C.for this reason Firepl/Fact.Blt. ICBG# — PLUMBING $ ISSUANCE $ 0
Date Owner . 1 Heating System& Ducting BOM 4. )0 PLAN CHECK 25% $ • ENERGY P.C. $
I hereby certify that I have read this application and state that the above fro-100,000 BTU 0100,000 BTL ELECTRICAL 450 GRADING $
information is correct. I agree to comply with all city and county ordinances EL $
and state law dating to building co uction, and hereby authorize repre- PLAN CHECK 50% $ MICROFILM $
sentatives o t '- city to ter upo UP he above-men)ioned property for
inspection p•'••ses.
Reinspection Fee $15 Issue Fee $ 3 PLAN CHECK 25% $ .
CMF 0865-46.rev.4/84 White-Building; Canary-Applicant;Pink-Accounting;Goldenrod -Assessor
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�•1 CONSTRUCTION AND PLANNING POOL _SPA
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
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-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 & 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
33. Final Electric •
'/ Notes:
34. Final Heating & Air Conditioning `/'^�.{��r-- Lid
35. Final Gas Pipe-Test '
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
48. Special Requirements Completed
49. Electric Release to Edison •
50. Gas Release to Southern California Gas Co • •
51. CERTIFICATE OF OCCUPANCY , • _
No. Date •
/ i �;6 FEB 20-70a618* ***11114.75
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626
For Applicant to Fill in Completely APPLICATION FOR BUILDING PERMIT
RECEIVAD e DATER IVE DATE ISSUED
BUCEILDING VAD 106 The Masters Circle t Acr .-- 02-_2_e-?7,.
PERMIT Nelti
OWNER United Savings & Loan Assoc. A.P. NO. f ? I Fi
AMAIL
DDRESS 9800 S. Sepulveda Blvd. BUILDING / k c iotpe ,. .O-
ADDRESS D �,C< �T'G��
D O CITY Los Angeles, Calif. NO.wlli 670-7550 TRACT 4c--6 ,g LOT 1-/8 BLOCK
I- Z
Z Q CONSTRUCTION NEW ADD ALTER REPAIR MOVING OFMOI ISH
O N LENDER Owner
am
_in BRANCH y/
-I to OWNS vi✓`l
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CO-i w VALUE y^ /� N
m ARCHITECT TEL. US ✓f� $o[ /,-T�O.
J N OR ENGINEER R.J . Mary i ck NO 839-3840 (/)/
Z Q FIRE c,
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w ADDRESS 1538 N. Century, Santa Ana ZONE TYPE GROUP
C°44-
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APPROVED /%d
J Z CONTRACTOR Ryness-Smith Co. BY , DATEJ / f/
03 J
W w ADDRESS 140 E. Industry Ave. �9 Y
w W TEL. ZONE NO.OF USE OF NEW„.. J
Z 1- CITY La Habra, Calif. No. 879-31 1 1 rh. 24-A I IPLANS� BUILDING LA,1 �
STATE CITY YARDS APPROVED YARDS APPROVED
u)2 LIC. NO. 167538 LIC.NO. 1964 MAIN BUILDING ACCESSORY BUILDING
D 0 -SIZE (FROM C/L STREET)
NO.OF BLDGS.
OF LOT 46 X 103 NOW ON LOT - FRONT s g FT. FT.
USE OF ✓T
EXISTING BLDG. R.SIDF 3 FT. FT.
f- SIZE OF NO.OF / /
Z NEW BLDG. 1824 ROOMS 6 STORIES I L.SIDE G FT.( _
(..1 FT. _
EXTERIOR WALL ROOF
COVERING YrUCCO COVERING Cedar Shingle REAR / 3 FT. FT.
-J USE OF BUILOING AND WORK TO BE PERFORMED DISTANCE BET. BET.MAIN&
fCL l MAIN BLOCS. ACCESS BLOCS. /
Q VAR.Ma L-_ 1Z DATE c 6 lD
0 Single family dwelling S. two car C.U.P.#tL (, APPROVED —/y-6l/
I•- APPROVED
/A attached garage _Ay / DATE / /7d
Z Lot 48 Plan I-B /
0
pI hereby acknowledge that I have read this application and state
7 that the above information is correct and agree to comply with
CC all laws regulating building construction, and I shall not employ
I- any person in violation of the workman's compensation laws of
the State of California. [� (y m
Z 1/rf PN SQ. FT. c )/T o
I hereby certify that I am properly licensed as a contractor under �P(/
the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UND VALUATION IS FOR di
Chapter 9, and that such licenses are in full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: Q
am exempt from the provisions of the State of California Business VALUATION
and Professions Cod Division 3,Chapter 9. /� ('�G m
PERMIT FEE $ % I J N
7
Signature of y/f D
Permittee Ai e- 4) , $ • PLAN CHECK $ �U ' E
�;/%////Jfj a 7 Vat dy/,, �J S— LL
Authorizetl Agent .�y��" "„ - i�����?/lIN�YJ �J/'` ✓ r TOTAL FEE / /,5
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