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HomeMy WebLinkAbout2053 Tustin Ave - Building Permits ;Yj_x CITY OF COSTA MESA• - t BUILDING DIVISION >:j 4 DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER �. !� PERMIT % omaeF E05-0101 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.c.a.usCAL PERMIT 77 FAIR DRIVE,COSTA MES ,CA 92626 ELECTRIJob Address: 2053 TUSTIN AV Status: ISSUED Suite No A Applied: 09/27/2005 Vicinity: UNIT A KITCHEN Issued: 09/27/2005 Parcel Nunmber: 42623214 Applicant: OLSEN, JEFF , / Address: 7522 SLATER AV ISSUED BY: a UNIT 111 Phone: 714-337-9611 HUNTINGTON BEACH,CA Zip 92647 Owner: MATHEWS, NEDRA MARGARETTA Address TR NEWPORT BEACH,CA Phone: 1867 BONAIRE WAY Zip: 92660 Contractor: EXCEL ELECTRIC AND SYSTEMS Address: 7522 SLATER AV UNIT 111 Phone: 714-337-9611 HUNTINGTON BEACH,CA Zip: 92647 License:707089 SCOPE OF PERMIT ELECTRICAL OUTLET FOR INSTALLATION OF NEW KITCHEN HOOD IN UNIT A. 1 RES APPL NO OTHER WORK AUTHORIZED WITH PERMIT. FEE SUMMARY Quantity Quantity ISSUE FEE $2350Temp Dist System/Lighting $0.00 0 Temp service test $0.00" Busway/100 ft $0.00 0 Res.a/c package $0.00 Standing Section $0.00 0 New Res(1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res(3+units) ' $0.00 0 Transformers up to 1 kva/kw $0.00 0 Pool/Spa $0.00 0 up to 10 kva/kw $0.00 0 Lighting Fixts $0.00 0 up to 50 kva/kw $0.00 0 Recept Outlets $0.00 0 up to 100 kva/kw $0.00 0 Switches $0.00 0 over 100 kva/kw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $4.75 1 Low Volt Wiring System/Ckt $0.00 0 Service to 200a $0.00 0 Misc.Conduit $0.00 0 Service to 1000a $0.00 0 Misc.Conductor . " $0.00 0 Service over 1000a $0.00 0 Circus(gen or ride) $0.00 0 Motors to 1hp $0.00 0 Circus(mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand" $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $28.25 Intermed Pole $0.00 0 nnuuuere. I once,.Ar nnunrrtnuo 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 244646(6/00) DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 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. 5 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. `('two workers'comae;atl1dn_In rance captor and policy number are: r� J (� pouter 4 �(91w — Pol`}cy'NOmboer: 1 7 r ) ) f i (This section need not be co plated if the permit is value 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 California,and ree that I I should become subject to the workers'compensation provisions of Section 3700 of the bor Code,I shall forthwith comply with these provi ns. �� G Applicant Siirlature: 1j WARNING:FAILURE TO SECURE W ERS'COMPENSATI ERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDRED THOUSAND DCLLARE(S1W,W0),IN DITION TO THE COST 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 0 C ter g(commencing with Section 7000)of Division 3 of the Business anq.Prplesgions Code,and my license Is In full force and effect.Ucrfl 7 0 7 D '�V�\j Class L( 1l Coniracto?sSlgnewiei"'- Data: "1 7.7 8 \-�^ ti-- 111 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 civil 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 appy to en 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 driver's license. 1 Yes 0 No Drivers 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,faisework,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 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 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 0 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 en RMPP is presently required,has Section 25534 of the California 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 akEermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LJ No (Section 65650.2 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? 0 Yes 0 No T (If'yes",the facility must meet the requirement of Sections 25534 and 42303 of the California 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 Cade 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. Signere Of Legal I er Date "j 7 I aigid,or orized- p6ciiiit -3 Spate CODE r INSPECTION TYPE DAIS RLELS CODE! INSPECTION TYPE Mg =AL4 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 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 , , � CITY OF COSTA MESA < BUILDING DIVISION -• l.,;� ."� DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER Fr ',nisei I a�/�a PERMIT M05-00 6 (714)7',544-522773',3•• Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 2053 TUSTIN AV Status: ISSUED Suite No A Applied: 09/27/2005 Issued: 09/27/2005 Vicinity: UNITA KITCHEN Parcel Number: 42623214 - - ISSUED BY: 4L' Applicant: OLSEN, JEFF Address: 7522 SLATER AV . . UNIT 111 Phone: 714-337-9611 HUNTINGTON BEACH,CA. Zip: 92647 , Owner: MATHEWS, NEDRA MARGARETTA Address: TR . . NEWPORT BEACH,CA Phone: 1867 BONAIRE WAY Zip: 92660 Contractor: OWNER-BUILDER Rii, Address: Phone: Zip: I •I• License:000000 l'e • SCOPE OF PERMIT - - INSTALLATION OF NEW KITCHEN HOOD IN UNIT A. 1 HOOD W/MECH EXHAUST ' NO OTHER WORK AUTHORIZED WITH PERMIT. FEE SUMMARY ' Quantity 1. Quantity ISSUE.FEE $23.50 Repair/Alt Absorbtion Unit . ' $0.00 0 Inst FAU<100 k BTU $0.00 0 Repair/Alt Refrigeration Unit $0.00 0 lest FAU>100 k BTU $0.00 0 Ventillation System $0.00 0 Repair/Alt Cooling/Heat,; . $0.00 0 . Evaporative Cooler ,$0.00 0 Inst/Rep.Recess Wall:Htr $0.00 0 Commercial Incinerator $0.00 0 Refrig Sys<100 k BTU , $0.00 0 Domestic Incinerator - $0.00 0 Refrig Sys>100 k BTU." $0.00 0 Compressors/Absorption Systems , Gas Piping .$0.00 0 Up to 3 hp/.100 k BTU $0.00 - 0 Factory Fireplace . ' $0.00 0 3 To 15 hp/500 k BTU $0.00 0 Hood w/Mech Exhaust $10.65 1 15 To 30 hp/1,000 k BTU $0.00 0 VAV Box $0.00 0 30 To 50 hp/1,750 k BTU • $0.00 0 Vent Fan/Single Duct . , ' $0.00 0 Over 50 hp/Over 1,750 BTU - $0.00 0 Appliance $000 0 Boilers , Fire Dampers $0.00 0 Up to 3 hp • • $0.00 0 Smoke Dampers $0.00 0 3 To 15 hp • $0.00. 0 Inst or Relocate Appl Vent- $0.00 0 15 to 30 hp:.,' , $0.00 0 Air Handlers< 10000cfm $0.00 0 . 30.to 50 hp - $0.00 0 Air Handlers> 10000cfm $0.00 0 Over 50 hp $0.00 0 Floor Furnace - $0.00 0 - Other Mechanical Fee Floor or Suspend Heater $0.00 ,0 . Investigation Fee . $0.00 Plan Check Fee.., $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $34.15 COMMENTS/SPECIAL CONDITIONS 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 16/00) DECLARATIONS 1 li - v WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 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. ❑ 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'compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if 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 Califomia,end agree that if I should become subject to the workers'compensation provisions of Sectio 3700 oft Labor Code,I shall forthwith comply with these provisio �1 /�. r kart SS gnatuie Date:`-r ( i L 7 D> WARNING:FAILURE TO SECURE WORT ERS'COMPENSATION W RAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL P NALnES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLlARE($1W,000),IN AD (TION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 37060F THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under 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.Lic.# Class# Contractor's Signature: 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). Lender's 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 pursue to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the usiness and Professions Code)or that he or she is exe therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant fore permit - jects the applicant to a civil penalty of not more thin'ive hundred dollars($500).): I,as owner of the property,or my employees with wages a4,their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec. 7044,Business and Professions.0 e: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 miner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). • ❑i 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 exem t under sec. Business and Professions Code for this reason: ?Signa e'' �� (•nate:-'9/27/6r Owner ID verified dri•ve s llc nse. 0 Yes 0 No D`nver ss litcrt a Nod- ExplrelTr —, Verification of Own rship by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: O 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,Califomia 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 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 standard temperature and pressure). Does or will the applicant or present ..t or future building 2 Does or will ant or present or future boccupant need to file a registration forth for acutely hazardous materials? 0 Yes ❑No (Section 25533 of the Califomia 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 Califomia 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? ❑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 aQermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes U No (Section 65850.2 of the Califomia 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? 0 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 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. Ignature Of a al O Date ILitA Or Auth d, t Date__: t CODE t INSPECTION TYPE 2AIF INTITIALS CODE• INSPECTION TYPE PATE 1616 Fixed System Final Fire Prevention 206 Final Mechanical 9-,!-)R`05 iirrVal 1266 Pool Spa Final 208 Final Plumbing 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 . I . . , 4 DECLARATION OF AUTHORITY Bldg. Permit# FOR AGENTS OF PROPERTY OWNER This Permit# TO APPLY FOR PERMITS Street Address: Zo 5 3 `-T/5 n ti �cre. c '#vi r 1� AP Number: 1. I (we), 4/e-4>M Lu - E7 W,e.t_._I . , declare that I am the Owner of Title of the above referenced realTproperty, and that I (we) hereby authorize: Q Name: V q( e �"� / Telephone Number: 7/19-n7%/ / Street Address: �7 r7 Z Z .5Z -7:42-, _ v'vir#///�j yam] City: [ //t7 1 �j71l-tit (�X�9-&& State: Zip: / ` yno - ooS^S-4 1 • to obtain permits in my behalf,as owner/builder,for 1t- O S — 0/ tO I z-- at the above referenced property. 2. Should any person become an employee engaged in the improvement of the property, I (we) shall immediately provide Worker's Compensation Insurance coverage and cause a certificate of that coverage to be filed with the Building Division of the City of Costa Mesa,as required by State of California laws. 3. As owner/builder in fact, I understand and accept that my responsibilities do not transfer to any other person, company or corporation. 4. I agree to indemnify and hold the City of Costa Mesa and its employees or officers harmless from any claim resulting in damage or personal injury to myself or any other parties as a result of work authorized by the permits from the City of Costa Mesa. 5. I declare under the penalty of perjury that the foregoingpis true and correct. //J� Executed this ar. day of Set Vas' 20p5 , at 'JP�t ( '"�— ,California. Print Name: N a D ga OA k- fl e 4/1/s Signature: G(� `//�%(""" ' 4. Date: 1 Zb -05 Note: This authorization does not grant authorization to perform the work as owner, it solely provides for limited power of attomey to secure this permit in any behalf. 0779-46(rev.11(00)