HomeMy WebLinkAbout304 16TH PL - Building Permits CITY OF COSTA MESA
4 BUILDING DIVISION
i ____ DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
!h . PERMIT
i+t '"�F B01-01488
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.mug 77 FAIR DRIVE,COSTA MESA,CA 92626
BUILDING PERMIT
Job Address: 304 16TH PL Status: ISSUED
Suite: Applied: 09/24/2001
Vicinity: Issued: 09/24/2001
Parcel Number 42521201 Zoning:
Applicant: BURKE, MICHAEL ISSUED BY: •
Address:
Phone: 949-642-7222
•
Zip:
Owner: COULTER, LAWRENCE L .!y
Address P O BOX 10035 _ .q � )
Phone: Y �l{� Y
BRADENTON, FL Zip: 34282
Contractor: LEE ROOFING OF COSTA MESA pp+'t£ ` a
Address: 1653 SUPERIOR AVE
Phone: (949)642-7222
COSTA MESA,CA
Zip: 92627 License: 349686
Arch : • Eng:
Address: Address:
Phone: Phone:
Zip: License: License:
SCOPE OF PERMIT
TEAR OFF CAP SHEET ROOF. INSTALLNEW HOT TAR WITH CAP SHEET BUILT-UP ROOF SYSTEM.
FEE SUMMARY
Plan Check: $0.00 Calc Valuation: $3,100.00
Permit: $97.25 • Claim Valuation: $3,100.00
SMIP Res: $0.50
SMIP Corn: $0.00
Other: $0.00
Inspection: $0.00
Total: $97.75
•
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
NOTES: •
•
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.
❑ 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 et one hundred dollars($100)or less.)
J
❑ I certify that in the performance of the work • which this permit Is issued,I shall not employ arty person in any manner so as to become subject to the workers'
compensation laws of California,and'• //JJil if I sho Id become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these p • •ns.
Applicant Signature: i Date: 17/-0
WARNING:FAILURE TO SECURE WOR -S •• PENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL RNES UP TO ONE HUNDRED
THOUSAND DOLLARE($1%,0001•IN'•DITION 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 provision 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: Alori..i ' Date: ?-,2 V-0
CONSTRUCTION LENDING 'GENCY:
❑ 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 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 perms'
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
O 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.).
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,Califomia Administrative Code).
O 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 ❑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? 0 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 Wan 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 kaermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? U 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 California Health and Safety Code).
Coast
Ar Quality
erne
7 If a permit from the South res cri ed Management DistrictHeor other airpollution ooncontrol district03 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 slate 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.
j gnature/if Legal Owner(s) Date
And/Or Authorized Applicant Date
CODE I '--selloff MI DATE INTITIAL$ CODE I INSPECTION TYPEpA�• INTITIAL$
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
I
PROJECT ADDRESS: 304 16TH PL UNIT: CITY OF COSTA MESA - BUILDING PERMIT PERM NO: d 0969E
OWNER'S NAME: COULTER
mum P_O. BOX 10035 PERMIT NO: B 059696 PLAN CHECK NO: N GOVT; .N SUPP: U
B RAD ENTON • Ez,.i
FL 34207 /7 CONSTRUCTION TYPE: rN PERMIT TYPE: STR r RPOSc: rile
( 813)756-4531- .
ARCH/ENGINEER: REG.NO.: JOB DESCRIPTION : REPAIR MINOR DAMAGE TO HOUSE FROM CAR SQ FT: 1 , 000
ADDRESS: UNIT:
CLAIM VALUE: 1 , 000 . 00 CALL-VALUE: 1 , 000 . 00 GROUP OCC: R-3 /
PERMITTEE PARTNERS CONSTRUCTION ( 714 ) 778-2616
ADDRESS: 708 N . VALLEY E COMMENTS: REPAIR WALL AT THE FRONT OF THE FBFHOJSd. SOR
ANAHEIM CA 92801 **** #*#*#*****tr###s6#�F�F******#*#�F* ##sF;6***** -x#x#*#x+6#x#� MUKE DETECTOR
LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section ZONING REQUIREMENTS
7000)of Division 3 of the Business and Prolessions Code,and my license is in lull force and effect. SETBACKS REQUIRED
CITY LIC.: 02961 STATELIC.:416556 M�c�s"s�}j
VOIVLo VA A` ° l MAIN BUILDING ACCESSORY BUILDING
nate. hereby¢: FRNT: FT IN REAR : FT IN FRNT: FT IN REAR: FT ..N
WORKERS'COMPENSATION DECLARATION: I hereby affirm that I have a certificate of co/mat:self-insure self-insure or a certificate of Workers'
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.: W P 91 15 3 81 01 EXP.DATE: 11 /09/92
•IMPANY: FREMONT COMP PARKING REQ• PROV: PARCEL : 42521201 ZNE: REF NO:
Certified copy is hereby furnished. IN Certified copy is filed with the city Building Division. PLANNING NOtES> .. ,
_, Date: ibKS(ci'IApplicant: ilda Vthicil >
********##****RE**** -*tSy6*##*#***************#*#************#*#***#*sa.drJ{'*#**#***##
EXEMPTION FROM WORKERS'COMPENSATION DECLARATION: (ills serum need not be completed it the perm)b for one hundred(5100)or less). D E V E L O`V R E N T SERVICES R E Q U I R E M E N-�I: S
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. ZONING APPROVED BY ^, 0 •
DATE; '
Date: Signature.shom
BUILDING APPROVED BY ?
NOTICE:It.aver making this declaration..you should Deme subject to the Workers'Compensation provisions of the Labor DATE:.
Code.you must forthwith comply with such provisions or this permit shall be deemed revoked. .-•1
CONSTRUCTION LENDING AGENCY: I hereby Atm that there is a construction lending agency(or the performance of the work for APPL I CATION ISSUED B Y•- i_ _� ,_4 ��.�'—' DATE: 4 ea
which this permit is issued(Section 3097.Civ.C). *******************ytt . . . . .x xir «-e rr*ye* ••rtxs • ..g ° ',` ' x - -.******####n (54is t tc.t
UNDER: *****************#io*************** ******* '** W ********************************
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 Cade: Any city of county which requires a permit to construct.alter,improve,demolish,or PERMIT 25 . 00 50
repair any structure.prior to its issuance.also requires the applicant for such permit to file a signed statement that he/she is licensed
pursuant to the provisionsof the Contractors'State License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business PLAN SMIP/NON—RES
and Professions Code)or that he/she is exempt therefrom and the basis for the alleged exemption.My violation of Section 7031.5 by
any applicant for a permit subjects the applicant to a civil penalty of not more than live hundred dollars($500). ISSUE FEE
•
I. as owner of the property or my employees with wages as their sole compensation. will do the work, and the BUILDING-DIV-> PERMIT ISSUE PLAN-CHECK TOTAL PAID DUE
❑ structure is not intended or offered for sale(Section 7044,Business and Professional Code: The Contractors Slate License Law TOTALS----> 25. 50 0. 00 0 . 00 25. 50 25 . 50 , . 00
does not apply to an owner of a properly who builds or improves thereon,and who does such work himself/hersell or through
his or her own employees.provided that such improvements are not intended or offered for sale.II,however the building or REVENUE DIVISION TOTALS--> COLLECTED• 25 . 50 OVER/SHORT: . 00
improvement is sold within one year of completion.the owner wit have the burden of proving he/she did not build or improve
" tor the purpose al sale). BLDG5PMT00 PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOOT GRADING )?.LAN-CHECK
I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business
❑ and Professions Code: The Contractors'State License Law does not apply to an owner of property who builds or Improves thereon
and who contracts tor such projects with acontractor(s)license pursuant to the Contractors Slate License Law).l am aware *********************************N'*****************#*******if-J6*****if-#4********Je*
that proof of their Worker's Compensation insurance should be provided to me. INDIVIDUAL F E E B R E A K D O d N
o I am exempt under Section: 8.d P.C.
for this reason: TYPE QTY DESCRIPTIO N UNIT COST 40TAL COST
Date: Owner: SFR 1000 ALTER BY VALUE RESIDENTIAL NOZONE 1 . 00 ..•. 00 ,,e 1 , 000. 00
I do hereby unify that 1 am aware of and understand the requirements of California Health and Safety Code Sections 25505,25533,and END OF FEES •• I
25534 and that I or any Wture building occupant will/will not(circle one)need to comply with Said state codes and the requirements far a
permit far construction or modification from the Air Duality 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 agree to comply with all city and county
ordinances and slate laws renting to building construction and hereby authorize representatives of this city to enter upon the above'mentioned
property or inspection purposes.
Date: lb bh,( It Signature: JtWVl tUp
at
Driver's License or Social Security x:
1641-46 While—Building:Green—Code Enforcement:Canary—Applicant;Pink—Revenue:Goldenrod—Assessor
CONSTRUCTION AND PLANNING POC 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 Electr cdl UF ER Grnd. 57. APPROVAL TO COVER-GUNITE
7. Footi• is 58. Electrical Conduit•Undrgrnd.
8. Foca-d,t on 59. Gas Pipe, 0 Undrgrnd., Test
9. Water P, pe-Undrgrnd. 60. Backwash Lines, P-Trap, 0 Undrgrnd.
10. Structu\t' Floor System ' 61. APPROVAL TO DECK
11. Pronrrt•11 Sewer Line & House Connection 62. Backwash & Receptor-Final
12. Set Cap 63. Heater & Vent-Final
11_ Pr. rf 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 0Oil
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 (9_ ..9b64.4---76. Dry Standpipe
28. Lathing & Siding g. 441�� CAtel4 77. FIXED SYSTEM FINAL
29. Insulation I 78. FIRE PREV. FINAL
30. Drywall NailingI HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat 79. FINAL INSPECTION
32. Electrical Power Meter•Final • 80. FOOD CERTIFICATE ISSUED
. t
33. Final Electric Notes:
r
34. Final Heating& Air Conditioning ( '
35. Final Gas Pipe-Test
36. Hood or Canopy
37. Final Factory Fireplace
38. Final Plumbing •!_
39. Water Service-Final ,
40. Gas Service-Final
I ti
41. Solar Domestic-Final
42. Backf low Preventer I
43. Backflow Irrigation.
44. Landscape Irrigatiao System
45. Sound Attenuatiofi
4
46. Handicap Regulatioin // �} /�/J
47. FINALSTRUCTURE&BUILDING //4 r _ 1 / /` S e_ / �_ f[ aa-at
48. FINAL PLANNING. ' (( (( !! {t -
49. Electric Release to Edison •
50. Gas Release to Southern California Gas Co •
51. CERTIFICATEOF;OCCUPANCY
No. ' Date
W
111
i� AUG 1 0 1966
i OWNER SALEM, GEORGE DATE
.0 JOB ADDRESS 304 – 16th Pl. BUILDING PERMIT NO. 22792 -
\1 GENERAL CONTRACTOR R. M. Wilson VALUE $ 200.00
\,21 GENERAL
No. 117-231-01 LOT TRACT FIRE ZONE 3 DESCRIPTION OF WORK Add Alum.Dr.Cyr
im.7-7CTIONS Signature DATE _ GROUP J TYPE lV ZONE R2 to Res
So= -; SUBCONTRACTOR PERMITS ISSUED
Gas' DATE NUMBER
Water
Rough Corn. Refrig. 0 Air Cond. ❑
Rough Healing
Rough Plumbing
Miscellaneous
Prop. Swr. Line ❑ House Con. ❑ St. Swr. 0
Sprinkling System
Construction Pole •
Underground 0 Power f.7
Rough Wiring
Trenches ❑ Forms ❑ Steel Reinf. 0
Floor System
Bond Beam 0 Steel Reinforce ❑
Sheathing
Frame and Flashing
Lathing— In 0 Out 0
Plaster, brown coat
I? ❑ Air Con. 0 Final
,h, .ng, Final
Plumbing Fixtures, Final
Final Gas Test •
Electric Fixtures, Final
Building, Final ,&/71 e a 7 _
OCCUPANCY
Form su4-0M-3-63--S-B s 22792
22782 FEE RECEIVED
COSTA MESA BUILDING-SAFETY DEPARTMENT AUG 10 1964
P.O.BOX 317 COSTA MESA,CALIFORNIA rr��11FIINn(AFFNC��E����7TDppEPMMT..��ppr�l�
For Applicant to Fill In Completely APPA ATI&Cal%ER7 I
TYPE OR PRINT BUILDING
BUILDING �J //1/ For Office Use Only
ADDRESS gray
/� (t'I /
RECEIPT NO. PERMIT NO.
COSTA MESA, CALIFORNIA 7.-Z7q
//',�u�� �'`�yp // C -/ RECEI BY / �gWEI / ��1ICIIC HIIED
OWNER llW`1 QY'e'L \ S ei/j - // aC/ /60
MAIL BUILDING 3o / // /'' //L
ADDRESS ..Yet",@•••C-- ADDRESS L7L=� !V ((9 /� /��%J�
NO.n..2' - ZONE E I GRO N: j
CITY FIRE -3
l.c'iytLl /FL4'.r. (,-(1^ !//y/
AR' -TECT Ad./4/17 TEL. APPROVED ATE/
OF '!NEER�4.-7-i.e.
/� NO. nnn
`r //M/ rt4 ING �v (, � /
ADDRESS / / g� A/' / -a V` ��
//�J] Z/O,N'[ NO.OF USE OF NEW ` 1�
CONTRACTOR ///t///GLS!/( 1 v U , PLANS) 1...____I
BUILDING 3.( /I L?'
ADDRESS /t cI/J 3TC Hair AA'I( LEGAL
DESCRIPTION 00
i? to )- i t/DT//A`��
CITY mss.///l C/YI'sr. A.P.NO. i I / 4)3 1 4-1
(/� V
STATE /5-1512/1 NO " r /—Glge(/ 90'r TO SIDE&REAR P.LE: NO EAVE NG SHALL BE LESS THAN
LIC.NO.
! EAVES
SIZE 1 /'C „, I NO.DFBLDGS. ALLOWED (U.B.C.REQUIREMENT)
OF LOT T ) /� f/T� Now On IDi
USE OF YARDS APPROVED YARDS APPROVED
EXISTING BLDG. MAIN BUILDING ACCESSORY BUILDING
(FROM C/LSTREE ) •
SETBACK LINE FROM �r �
CENTER OF STREET REAR YARD FRONT �'y�
SIDE YARD I LEFT I RIGHT R.SIDE .J�ry PT. FT.
DESCRIPTION OF WORK L.SIDE ^99'! FT. /,'//y( Fr.
NE ALTERATION _ ADDITION T REAR ti O . .�(// Ff'
DISTANCE BET. 1 BET.MAIN B
REPAIR MOVING DEMOLISH MAIN BLOCS. ACCESS.SLOGS.
BUILDING NO.OF VAR.# DATE
SIZE ROOMS STORIES C.U.P.# APPROVED
EXTERIOR WALL I ROOF
APPROVEDtail .7,10_6k../
COVERING _ �iflJ(9E
US OF BUILDING AND WORK TO BE PERFORMED 11 Jr/N /
AVM di l/sem
N
SQ.FT. S
I HEREBY ACKNOWLEDGE 'HAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE F'
[NO
STATE THAT/THE ABOVE IS CORRECT AND AGREE TO COM. PURPOSE OF ESTABLISHING A PERMIT FEE ONLY.
LY WITH ALL,CITY/ORDINANCES AND STATE LAWS REGULATING
VALUATION - St UILDING CONSTRUCTION! ////�� ,�/
ERMITTEE �7I� /��' ^' , 'G`� U� ,
IGNATURE OF PERMIT FEE S � PN CHECK Sr
cr
ISO UTHORIZED AGENT TOTAL FEE