HomeMy WebLinkAbout2807 LORETO AVE - Building Permits CITY OF COSTA MESA
i a BUILDING DIVISION
>:l--. DEVELOPMENT SERVICES DEPARTMENT PERMIT N BER
1. 1 ; . .PERMIT
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(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.cILDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 2807 LORETO AV Status: ISSUED
Suite: Applied: 10/10/2005
Vicinity: ROOF Issued: 10/10/2005
Primary Occ: R3 Type of Construction: V-N
Parcel Number 14133221 Zoning: R1
Applicant: PARK, MICHAEL
Address: 8639 BUENA TIERRA PL �j
Phone: (800)726-7700 ISSUED BY: iA_// ��
BUENA PARK,CA - Zip: 90621
Owner: LAWRENCE
Address 2807 LORETO AVE
Phone: 949-290-0662
COSTA MESA,CA - Zip: 92626
Contractor:,; GOLDEN WEST ROOFING SERVICE
Address: 8639 BUENA TIERRA PL
Phone: (800)726-7700
BUENA PARK,CA
Zip: 90621 License: 735924
Arch : Eng:
Address: Address:
Phone: Phone:
Zip: License: License:
SCOPE OF PERMIT
T/O EXISTING ROOF MATERIALS AND INSTALL 1 LAYER OF 30#FELT AND REROOF W/30 YEAR COMP ES ON AN ATTACHED HOUSE
AND GARAGE,APPROX 2,500 SF.REPAIR AND REPLACE SHEATHING AS NEEDED.
FEE SUMMARY
Plan Check: $0.00 Ca luation: $6,500.00
Permit: $139.25 Clai luation: $6,500.00
SMTP Res: $0.65
SMIP Corn: $0.00
Other $0.00
Inspection: $0.00
Total: $139.90
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 ell
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)
DECLARATIONS
WORKERS'COMPENSATION DECLARATION: '
I hereby affirm under penalty of perjury one of the following declarations:
•
0 I have and will maintain a certificate of consent to self-Insure for workers'compensation,es provided for by section 3700 of the Labor Code,for thepertornance 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:
Gamier:--c-67:47-ro ? i 0 ff iece Numbei: O�� 2�
rgsectia+Tneed 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 h 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 agree th I shout come subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shell forthwith
comply with these provisions. r _
Applicant-Signet:: eec Date: /d 70 —
WARNING:FAILURE TO SECURE WORKERS'COMPE ATIO VERAGE IS UNLAWFUL AND SHALL SUEUECT AN EMPLOYER-TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE(5100,000),IN ADDITION TO THE 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 license under provisio of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Prof° sions Code,and my license Is in full
forceand eff ect_uc..n Clestt-'. e.—3
Contraotors5ignature: „r Dater-> / /0-- ye —a C —
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 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 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 ex :,.:%• '.a(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-UK!!nk 1. caffolding,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 Admin firtEri Code).
❑ As owner-builder,I will not : ay an 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: AY, Date:
Division of Industrial Safety Permit Number:
4 e+
HAZARDOUS MATERIALS AND EMISSIONS CERTIFTCbTION: ,�yy
1 Wit the applicant or present or future building occupant need tdifflP8(I rcertify 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 r e 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 q 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 an assure).
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 If an RMPP is presently required,has Section 25534 of the California Health and Safety Cade 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 a plication a ernit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes 0 No
(Section 65850.2 of the California Govemment Code requires that the requested information be furnished on applications for non-residential building permits).
_ _..l ._.._._
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a schchool?? ❑Ves 0 No
(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 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 COMPUANCE 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.
Sig Lire Of Legal Owner ) Date
~"' #Or Autlfan zed kart 1: oeta�
CODE A INSPECTION TYPE 26)1 MALE • RODE I INSPECTION TYPE RATE RCM ,
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final ) / 208 Final Plumbing
200 Final Re-Roof lb-13196'
I!- t3rOG 210 Final Electrical •
201 Final BlocldRetaining 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 - '-
.oJECT ADDRESS: 2807 LORETO AV UNIT: CITY OF COSTA MESA — BUILDING PERMIT PLRel NO: d c,4957-,
OWNER'S NAME: JOHNNY SLOGAN • -
ADDRESS: SAME AS ABOVE PERMIT NO: B 099577 PLAN CHECK NO: N (v v 4 : pi at EP: :v
CONSTRUCTION TYPE: PERMITTYPE: STR PURPOSE: ALT
714 /540-4805 •
ARCH/ENGINEER: RE&ND.: JOB DESCRIPTION REROOF SQ FT: 5, 200
ADDRESS: UNIT:
CLAIM VALUE: 5, 200 . 00 CALL VALUE: • 5, 200 . 00 GROUP OCC: R-3 /
PERMITTEE: PETERSON ROOFING ( 714 ) 720-0812
ADDRESS: 2816 PCH COMMENTS: SMOKE DETECTOR REQUIRED
CORONA DEL MAR CA 92625 *�E**9E* F**a6** r **yrs*** �E �Eir*a6*�t*�r �r-E***�E * * ***�E E* E � �P**�6 �E *�6�6*****a
LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section Z G N I N G R E Q U I R E M E N T $
7000)of Division 3 of the Business and Professions Code.and my license is in full force and effect. S E T B A C K S
CITY) 5 STATELIC.:468553 CLASS: C-39
�_Z'�J" QC7 MAIN BUILDING ACCESSORY BUILDING
signature:—� FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN
r-
, "10 RS'COMPNSATION DECLARATION: I hereby affirm that I have a certificate of consent to self-insure or a certificate of Workers' LEFT: FT IN RGHT : FT IN LEFT: FT IN RGHT: FT IN
mpensation in:�ra�cq.3r s nerOfied copy thereof(Section 3800.Lab.04 /01 /91
JLICY NO.: S J EXP.DATE:
COMPANY: STATE A� PARKING REQ: PROV: PARCEL : 14133221 ZNE: REF NO:
D Ce• opy is hereby furnished. LJ Certified copy is filed with the city Building Division. PLANNING NOTES>
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a � Applicant: 10-2-3 'I D
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DEVELOPMENT SERVICES REQUIREMENTS
EKE • :'FROM WORKERS'COMPENSATION DECLARATION: (This section need not be completed if the permit is for one hundred($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 ZONING APPROVED BY
' subject to the Workers'Compensation Laws of California. DATE:
Date: Signature: BUILDING APPROVED BY
NOTICE:If.after making this declaration,you should become 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.
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for APPLICATION ISSUED BY: / DATE: /6 9d
which this permit is issued(Section 3097.Civ.C). iEBfif Bf*******if#iEB69F9f BfiE9t Bt Be#ie#BE1f*BEBf1fdERE9e Be (**9i"iF')E**iE********if1FBe1EJf1E1E?FiE*M - • •BE*
LENDER: Bf***Bf BEiE***BE#1fiEiE#9F*3Ejf BE3f Jf*ikifiFBf3FBE**BEBE1f1E**9EBEBf BEBe?F9F*%BfiFiflf9fiEJfjf3Eif**3k%***B!*7fiE-k Beif.)EBii4*ff*BE*
ADDRESS: LEGALIZATION:N F E E S U M M A R' Y STRUCTURAL SEGMENT:Y-
OWNER BUILDER DECLARATION: I hereby affirm that l am exempt from the Contractors'State License Law for the following reason PERMIT BLDG
81 PMT00 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 . 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 SMIP/NON—RES
pursuant t0 the provisions of the Contractors'State License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business PLAN '
and Professions Code)or that he/she is exempt therefrom and the basis far the alleged exemption.Any violation of Section 7031.5 by
ISSUE FEE
any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).
BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK . TOTAL PAID DUE
I. as owner of the property or my employees with wages as their sole compensation, will do the work, and the TOTALS-----> . . . 81 . 50 0 . 00 0 . 00 81 . 50 81 . 50 . 00
z❑ structure is not intended or offered for sale(Section 7044,Business and Professional Code: The Contractors'State License Law ' '
does not apply to an owner of a property who builds or improves thereon,and who does such work himself/herself or through
his or her own employees, provided that such improvements are not intended or offered for sate.If.however the building or REVENUE DIVISION TOTALS--> COLLECTED: 81 . 50 OVER/SHORT! • . 00
improvement is sold within one year of completion.the owner will have the burden of proving he/she did not build or improve BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK
tor the purpose of sale). 81 . 00 . 50
•
I,as owner of the properly,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 **, *****, ***, ******* **, ***, ***, **, ,x16 if*,IE BE#1E*)f ff,N,1E*1f,)E**>4********>4 4*7E-1E%%,>F if,1E 1E 1f iF 1E*
and who contracts for such projects with a contractor(s)license pursuant to the Contractors'State License Law).I am aware
that proof of their Worker's Compensation insurance should be provided to me INDIVIDUAL F E E BREAKDOWN
❑ I am exempt under Section: B.8 P. C.
torthis reason: TYPE QTY DESCRIPTION - UNIT COST TOTAL COST
Date. Owner: SFR 5200' REROOF BY VALUE RESIDENIAL NOZONE 1 . 00 5, 200 . 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 Quality 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 state laws relating to building construction and hereby authorize representatives of this city to enter upon the above-mentioned
prope�inspection purposes.
`D:{�r� �_ signature. 10 23 �d.\ 01 00072647-00072643 T n T 31.50
ody�ic .:.�.orsoa DATE: 10/23/90 TINE: 12:23
1641-46 White—Building:Green—Code Enforcement;Canary—Applicant:Pink—Revenue:Goldenrod—Assessor
4
•
CONSTRUCTION AND PLANI<lli- I r^OOL & SPA
Date Inspector Date Inspector
APPROVALS Permit # _ I APPROVALS Permit # , I
. 1. Temporary Electrical Service or Pole ,, 52. Pool & Equipment Location - ,� u `
2. Soil Pipe-Undrgrnd. I. ,1 53. Steel Reinforcement -i'•
3. Electrical Conduit Utility-Uridrgrnd. • 54. Forms , 1
4. Electrical Conduit-Undrgrnd. i ' 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 - " i 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 ElectricWiring 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 Facto{y Fireplace ' '''" I I 'APPROVALS`) -:Permit # t
21-..Ducts,in Structure " . , - 70. Underground Hydro '
22. Ducts, Ventilating' i r (,.1. : .71. Product Piping 0 Gas 0 Oil
h &Test . ; t• , • ''
23. Gas Pipe-Rough ,t. •72. Underground Flush t
24. Roof Framing A ` ; ' r • 73.'Undergrnd.Storage:Tank'El Gas 0 Oil •
25. Roof Sheathing . - - . •• , i 74,,Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat 'r' I•' ; : 75.:Dry Chemical e '
27. Frame and Flashing • _ 76. Dry Standpipe '.•�
28. Lathing& Siding: " i • I ••,1 y- 77,' FIXED SYSTEM FINAL
29. Insulation ' - i n 78. FIRE PREV. FINAL "
30. Drywall Nailing I HEALTHtDEPT. REQUIREMENT
31. Plaster Brown Coat I 1 1 79? FINAL INSPECTION , -
i • •80.-iFOOD CERTIFICATE ISSUED
32. Electrical Power Meter-Final a i i I, ,
•33: Final Electric i.` I Notes: . •
34. Final Heating& Air Conditioning - i - -i• • r '
35. Final Gas Pipe-Test , -
.36. Hood or Canopy I - • I
37. Final Factory Fireplace. • i : f • • c•
38. Final Plumbing I I 1' • .S
39. Water Service-Final - i I I rf, ' 'i•I
40. Gas Service-Final +. i i
41. Solar Domestic-Final . . I' ,
42. Backflow Preventer i - ` , •
43. Backflow Irrigation 1 '�
ir , • - -
44. Landscape Irrigation System ,. a ' •
45. Sound Attenuation I • I • ' •"
46. Handicap Regulations - • .
47. FINAL STRUCTURE & BUILDING gi i� ��
48. FINAL PLANNING I , •
49. Electric Release to Edison ••-' '!
50. Gas Release to Southern California Gas Co ` � , , t •
51.. CERTIFICATE OF OCCUPANCY - r - -
• No. Date
DEC 9 •:1030
13462 1
(-.IYIU.CLC JLI r7
T.
COSTA MESA BUILDING-SAFETY DEPARTMENT P1l - OF COSTA i�i'-5:.
P. O. BOX 917 COSTA MESA. CALIFORNIA L0t. 26, yJ / �L .l 3/ e/
For Applicant to Fill In Completely APPLICATION FOR PERMIT
TYPE OR PRINT
BUILDING BUILDING
ADDRESS 2807 Loreto Avenue
COSTA MESA CALIFORNIA For Office Use Only
RECEIPT NO. T {4t2
OWNER Mesa Del Mar Development Co.
MAIL RECEIVED BY I DATE RECEIVED DATE ISSUED
ADDRESS 18n0 E Cone main - /'c- 4..2- 7- GO 16EP.o n boon
CITY Corona .del Mar • NSA 34220 ADDRESS 2807 Loreto Avenue
ARCHITECT TEL. COSTA MESA. CALIFORNIA
OR ENGINEERMaCCO Corporation MOOR 34220
ADDRESS 3800 E. Coast Highway -- FIRE /� , /f'i/' (� '
g $y ZONE TYPE ! GROUP �1 'it
CONTRACTOR Macco Corporation BYPPROVED DATE
ADDRESS 3800 E. Coast Highway ZONING
ZONE NO.OF USE OF NEVP1LI81 Pain•
CITY Corona del Mar R_1 PLANS 2 I BUILDING w/ att gar
STATE AffeAr _/ TEL. LEGAL .,mac 7� cS
LIC.NO. 7Q � '- NO. DESCRIPTION Xei �L 37s3
SIZE / / NO. OP BLDGS.
OF LOT 7 o X 9- 3 NOW ON LOT O A.P.NO. nnnP
USE OF YARDS EVES
EXISTING BLDG. r_ APPROVED j., ( ALLOWED
SETBACK LINE FROM '( CENTER LINE ST.) iigir
CENTER OF STREET L{S REAR YARD 3t1 FRONT T. o R IJ 3 ,.2-�
SIDE YARD I LEFT <1 I RIGHT : c/ R.SIDE ,OFT. IN.
DESCRIPTION OF WORK ,J
R.SIDE RFT. IN.
/J(
NEW ✓ (ALTERATION I ( ADDITION I REAR � FT, p /1 N.
REPAIR
V MOVING I V DEMOLISH I BYPROVED
D W . 7 . 1). DATE 12.8.60;
BUILDING NO. OF JJ00 ,_--,,-0 ,_--,,-C---""'L
SIZE ROOMS Co STORIES /
EXTERIOR WAL ,.- ROOF
COVERING ...12/440....04COVERING �L/p4.4. P - i15-9 sip
.
UG,, BUILDING AND WO PERFT//AL4-- j/ Si lr
•
/.CECIL./ -�LrA
HEREBY KNOWLEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE
ND STAT THAT THE ABOVE IS CORRECT AN AGREE TO COM-
PURPOSE OF ESTABLISHING A PERMIT FEE ONLY.
PLY WITH ALL CITY ORDINANCES AND STATE WS REGULATING
BUILDING CONSTRUCT ON/.//� VALUATION
SIGNATURE OF /�l� at, . !^ PERMIT FEE $ J 0-0
PERMITTEE { 6'^' - o
s 14, l 3 e.ep PLAN CHECK $ i 20.6
�1 I
AUTHORIZED AGENT TOTAL FEE 5 s 1. V4 D
e