HomeMy WebLinkAbout1621 BAKER ST - Building Permits Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations.
'P9 OF COSTA /N'1 S C1O'NNSSTRU ION PERMIT . PER NO 7/
TRACT NO. LOT NO. UNIT NO. YI 9115 4/21 /E:1 12605 11
c'ProjectAddress M JJlt- 3/ r' ' -
s s . TYPE OF CONSTRUCTION El NEW NEW ADD U ALTERATION U REPAIR
d APPlicant 's Mailing Address
• aet ❑ CONVERSION El DEMOLISH ❑ OT R A.P.# I Zone
Owner's Name
to Phon: ' - #m a DESCRIPTION OF ORK/USE OF BLDG. . SIn •2 t O.1' ad • a
A �
•.i.
Address •-a• •
. a e-- • • IL i �rr k
. • 0 , A. •• ei: • a J S Main Building: Accessory Building:
��� E Z
Arch/Eng. License No. TVPE OF PERMIT I. GRADING II F•UNDATION U STRUCTURAL T Front o
Address ❑ TENANT ❑ ELECTRICAL 0 PLUMBING El MECHANICAL A Rear N
❑ OTHER I
Contractor's Name Phone tI� C Right N
Address(mailing) I � PROJECT DESCRIPTION SQ. FT. 'Tgo OCCUP CY••���� •� K (•,
CONSTRUCTION TYPE VALUATION$ -71f ..J3 S Left
City License No. _ R
ZONE GRADING CU.YDS. ACRES Ping. Ref.# Parking Req./Provided E
LICENSED CONTRACTOR DECLARATION ,s �-� Q
I hereby affirm that I am licensed under provisions of Charter 9 (commencing Remarks:%A Nc,r e � � �•{Qz�,�,/�s� Planning Notes: rv1
with section 7000) of Division 3 of the Business and Professions Code,and ✓s,� ���s���••"�� "^• _ e'
my license Is In full torte and effect. �s ,, ._ ^flT
S
License Class License No. V�!/�//NM PLUMBING 1 FEES
Date Signature
'WORKERS'COMPENSATION DECLARATION Bar Sink Showers ELECTRICALFEES
,hereby affirm that I have a certificate of consent to self-insure or a certificate •
of Workers' Compensation Insurance, or a certified copy thereof (Section Backflow Preventer Service Sink1
3800, Lab. C.) Automatic Washer Transformer 0 15-50 KW
Policy No. Company Backflow Irrigation Sewer Cap Construction Pole Sub. 0 50+ KW
8 Certified copy is hereby furnished. —
Certified copy is filed with the city Building Division. Bathtubs Sewer Connection Cooking Unit Meter Oup to 100 amps •
Date Applicant
EXEMPTION FROM WORKERS'COMPENSATION DECLARATION Clarifiers Solar Collectors Dishwasher Meter Cover 100 amps
(This section need not be completed if the permit is for one hundred($100)or . Dishwasher
less). 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 ner so to become subject to the Drinking Fountains Solar Tank r Fan Motors❑0-I HP❑1 B:-B
Worker9{sComp`osa}f00 Laws of Calif rni D O - __
-
Dato ..T LI inn Signature 1/C! 9.... Floor Drains Swimming Pool w/Spa F.A.U. Ina Solar 0915 HP 016-15.1-NOTICE:If,after making this declaration you h Id become subject to the ,
Workers' Compensation provisions of the Labo ode, you must forthwith Floor Sinks Urinal Fixtures Microwave
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY Gas Service Outlets Water Closet Device
1 hereby affirm that there is a construction lending agency for the performance _ Boxes Pole Light
of the work for which this permit is issued (Section 3097 Civ. C.) Interceptors Water Heater Outlets Range
Lender's Name
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 I Auto-Wash Garbage Disposal Standing Sections
following reason (Section 7031.5tto Businessnconstruct,
t,and Professional Code: Any r city or
county which req vireo^itissuance,
c ,al oruct,alter,improve, t such
or repairmiP-Trap Laundry Trays Generator 00.5 KW 05-15 KW Trash Compactor
toy asigned
structure, psta em itst that he/, also requiresicesthe applicant for oof
to file a License
statement that he/she Is licensed pursuant to the provisions of Roof Drains
he Contractor's Linse Law(Chapter 9(commencing with Section 7000)of
)ivision 3 of the Business and Professions Code) or that he/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
enalty of not more than five hundred dollars(5500).
I, as owner of the property or my employees with wages as their sole Reinspection Fee I $15 Issue Fee S 3
compensation, will do the work, and the structure Is not intended or offered - - -- Reinspection Fee I $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 _ _ -
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 0
sale. If, however, the building or Improvement Is sold within one year of com- Canopy Type II 0 Zoning Approved By Date
prove f, the owner will have the burden of proving he/she did not build or im- Duct- Under Ground BuildingApproved By �p Date_
prove for the purpose he pf sale). -
�/, as owner tr tthe property, Se tion 7 44, contracting with licensedioncon- Duct-Structural Refrigeration System Application Issued By �/ Dat
hetors construct the project (Section apps osine and Professions t Code:
The %Contractor's License Law does not era t to an owner je isproperty who Duct-Ventilating 00-100,000 BTU 0100,000 BTU SU V OF EES
builds or improvesicense thereon,and who contracts for such projects with r con- �,/1 /y If�F
tractor(s) license pursuant to the Contractor's License Law). I am aware that Exhaust System 0 Multiple 0 System Repair/Alteration B G PERMI / f(/. OV SMIP $ SO
proof of their Worker's Compensation insurance should be provided to me. PLAN CHECK $ PERMIT
0 I am exempt under Section B.& P.C.for this reason Firepl/Fact.Bit. ICBG# Fire Dampers
PLUMBING $ ISSUANCE $
Date 4 & 6S Owner 1�,� • + AQ•yy Heating System& Ducting PLAN CHECK 25% $ ENERGY P.C. $
I hereby certify that I have read this pplicatipp ,and state that tie above 00-100,000 BTU ❑100,000 BT ELECTRICAL $ GRADING $
information is correct. I agree to comply with al City and county O dinances
and state laws relating to building construction,and hereby authorize repre- PLAN CHECK 50% $ MICROFILM $
entatives of t. city t• anter u•on the above-mentionedhe pr••' ty r
nspectiOn pun / I �• r• I MECHANICAL $ TOTAL FEE $ /�`2�
Drivers'riverure t.J ,i• • -
-Accounting; Goldenrod - Assessor
CONSTRUCTION AND:PLANNING POOL& SPA
APPROVALS /Perntir# Date Inspector APPROVALS Permit# Date Inspector
t ,
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 UFERGrnd. 57. APPROVAL TO COVER-GUNITE
7. Footings I; 58. Electrical Conduit-Undrgrnd.
8. Foundation I 59. Gas Pipe,0 Undrgrnd.,Test
9. Water Pipe-Undrgrncc - 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
C.
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. 11,
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT I
r
20. Rough Factory Fireplace APPROVALS Permit# ' I
- '
' I
21. Ducts, in Structure 70. Underground Hydro I1
22. Ducts, Ventilating 71. Product Piping 0 Gas ❑Oil s
23. Gas Pipe-Rough & Test 72. Underground Flush j
24. Roof Framing 73. Undergrnd.Storage Tank 0 Gas 0 Oil I . I"
i
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 i'
29. Insulation 78. FIRE PREV. FINAL `
30. Drywall Nailing - HEALTH DEPT. REQUIREMENT ••'
31. Plaster Brown Coat 79. FINAL INSPECTION •:!. I r-- •
32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED - 't r
33. Final Electric Notes: 1� • t
34. Final Heating & Air Conditioning j S....%"
35. Final Gas Pipe-Test
36. Hood or Canopy i
1
37. Final Factory Fireplace -
1
38. FinaiPltimbing I ..-
• 39'. Water Service-Final r - 'j
' 40. Gas Sefvjce-Final
. (4i. Solar Domestic-Final i^ . j
1 42. Backflow Preventer -
• 43. Backflow Irrigation -, '
^ •
44. Landscape'Irrigation System . I -
45.,Sound Attenuation I. ' ,
46'Handicap Regulations p -
47., FINAL STRUCTURE & BUILDING L/12.y/J sA 6'.P
48:Special Requirements Completed 6 ' .
49. Electric Release to Edison - -
50. Gas Release to Southern California Gas Co 4 i
51. CERTIFICATE OF OCCUPANCY 'r
No. Date s'-
PROJECT ADDRESS: 1621 BAKER ST UNIT: CITY OF COSTA MESA - BUILDING PERMIT PERM NO: B 056789
OWNER'S NAME: MELROSE, JOHN E
r, ADDREss: RIETSCH KURT PERMIT NO: B 056789 PLAN CHECK NO: N GOVT: N SUPP: N
1621 BAKER ST 92626
,' COSTA MESA, CA CONSTRUCTION TYPE: PERMIT TYPE: STR PURPOSE: DTH'
754-1753
ARCH/ENGINEER: REG.ND.: JOB DESCRIPTION : REROOF 1400SF RESID & GARAGE W/COMP SHIN SQ FT: 2, 500
ADDRESS: UNIT:
CLAIM VALUE: 2, 500 . 00 CALC-VALUE: 2, 500, 00 GROUP OCC; R-3 /M-1
PERMITTEE: KURT RIETSCH ( 714 ) 754-1753 `� /`�g
ADDRESS: 1621 BAKER ST COMMENTS: X ' �E I EV I oR
C.M. CA 92626 ********i************�E�E�E�E�E�E********** �E�E�E******* HESE****** t************
LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section Z ONING REQUIREMENTS REQUIRED
7000)0l Division 3 of the Business and Professions Code.and my license is in full force and effect. SETBACKS
CITY UC.: STATE LIC.: CLASS:
Date: Signature: MAIN BUILDING ACCESSORY BUILDING
WORKERS'COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self-insure or a certificate of Workers' FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN
4 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.: EXP.DATE:
COMPANY: PARKING REQ PROV: PARCEL: 13919309 ZNE: REF NO;
' 1 Certified copy is hereby furnished. ❑ Certified copy is filed with the city Building Division. PLANNING NOTES>
-4>
Date: Applicant: *******************************************************************************
EXEMPTION FROM WORKERS'COMPENSATION DECLARATION: (This section need not be completed it the permit is for one hundred($100)or less). D E V EnL O P M E N T SERVICES R E Q U I R E M E N',T 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 DATE:
Dale: Signature: BUILDING APPROVED BY : DATE:
NOTICE:If,after making this declaration.you should become subject to the Workers'Compensation provisions of the Labor -
'/
Code.you must foNG compIwith such firm t provisions this consrmit shall be deemed revoked.cfAPPLICATION ISSUED BY• ,Si) (t DATE• .Bt ( f alit-
CONSTRUCTIONisrmi LENDINGe AGENCY: hereby.Civ.CI.
that there is a construction lending agency for the performance of the work for
which this permit is issued(Section 3097.Civ.CI. *************************************iF*** **'*********************'**'*' * * ****
LENDER: *******************************************************************************
ADDRESS: LEGALIZATION:N F E E SUMMARY STRUCTURAL SEGMENT:Y
OWNER BUILDER DECLARATION: I hereby affirm that l am exempt from the Contractors'State License Law for the following reason BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES ';GRADING
(Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct,alter,improve,demolish,or PERMIT 54 , 00 , 50 '
repair any structure.prior to its issuance.also requires the applicant for such permit to lite a signed statement that he/she is licensed SMIP/NON-R
pursuant to 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 Iheretrom 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 penally of not more than five 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 ' •'•k0 DUE
❑ structure is not intended or offered for sale(Section 7044,Business and Professional Code: The Contractors'State License Law TOTALS----> 54 . 50 D , 0 0 0 . 00 5 4 , 50 54 , 50 /-� . 00
does not apply to an owner al 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 sale.IL however the building or REVENUE DIVISION TOTALS--> COLLECTED: 54 , 50 OVER/SHORT' 00
improvement sold within one year of completion.the owner will have the burden of proving he/she did not build or improve
foror the purpose off sale).
BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN-CHECK
(Se
,5, Professions
of the eh, Co tr osis'Sy tecontractingLicnwithw licensed not contractors to an to construct t project hb ills or i Prov,s Business
54 . 00 . 50 \,
LM and who Code:contracts
afThe ojectsowth State cose ntractor(s)
pursuant
to ownertepropertyotr 'Sate icenserimp.oI improves thereon *******************************************************************************
and who contracts for such projects with a license pursuant to the Contractors'State License Law1.l 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
forums reason: �- / TYPE QTY DESCRIPTION UNIT COST TOTAL COST
Date: �` '` �2 �omer. � ���i SFR 2500 REROOF BY VALUE RESIDENTIAL NOZONE 1 , 00 2, 500. 00
I do hereby certify that I am aware of and understand the requirements of Cali relealth and Sal*•e 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 .i es and the requirements for a
permit for construction or modification from the Air Duality Management District.Residential construction applications are exempt from
these provisions..
Date: Applicant:
I hereby certify Ilial I have read this application and state that the above information is correct I. • ply with all city and county ,. - •
ordinances and slate laws relating to building con ruction and hereby autho'e represema• y bn the above-mentione�
property for inspection purposes. , ,.r-.r
Date: LA`1.1- -66l Z Signature: 'J �`— D f 00111873-DM 11074 Y'Cif DATE: 04 0L192 TME: 89:riX
Drivers License or Social Security a: 7 /
1641-46 White—Building:Green—Code Enforcement:Canary—Applicant:Pink--avenue;Goldenrod—Assessor
SON$TRUCTION AND PLANNING POO WA
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 t
•
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 Electridal-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
19. Rough Heating& Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace • APPROVALS • Permit #
r
21. Ducts,in Structure• - 70. Underground:Hydro
22. Ducts, Ventilating ' 71. Product Piping 0 Gas 0 Oil
23. Gas-Pipe-Rough & Test72. Underground Flush -
24. Roof Framing - - 73. Undergrnd.Storage Tank 0 Gas 0 Oil
25. Roof Sheathing 4:M2 6(N41 74. Overhead Hydro-,
26. T-Bar Ceiling (Structural) & Monocoat _L • 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 I 79. FINAL INSPECTION
32. Electrical Power Meter-Final i 80. FOOD CERTIFICATE ISSUED )I{
33. Final Electric • Notes: _
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
41. Solar Domestic-Final
42. Backflow Preventer
43. Backflow Irrigation -
44. Landscape Irrigation System , ,.
45._Sound Attenuation
46. Handicap Regulations ' .
L
47. FINAL STRUCTURE & BUILDING • -8-G11 6w '`�- - ` '
48. FINAL PLANNING c(_3-'12- - S"`49 � _O._� Ole
49. Eleciric Release to Edison • a • 4t
`50. Gas Release to Southern California Gas Co I j I tv
51. CERTIFICATE OF OCCUPANCY .,
No. Date
OWNER CCMW.SA TM'. DATE 6-3-r9 -
JOB ADDRESS 1621 Baker Street BUILDING PERMIT NO. 9511
(''NERAL CONTRACTOR Ike and Cnlegrnve VALUE § 13,715.0n
•
No. LOT 99 TRACT 2822 FIRE ZONE DESCRIPTION OF WORK Res. at gar.
INSPECTIONS (../p. g DATE I GROUP J R- J TYPE V ZONE El
Underground Soil r}fs U.G. Water44K /-n - SUBCONTRACTOR PERMITS ISSUED
Underground Gas DATE NUMBER
Overhead Water and Gas /�� A l
Rough Heating / S J-29C ' A�'�'.I .P7 /--r /2), 7•.&/:5-Z. j?G6 9 / r
Rough Plumbing ,b,4 7-2.2.-- 9�AC-..7' ) ::!/c c� 6i--9-5%/`i`
Miscellaneous Y _ RR--_�C'�
Prop. Swr.CLine- Hdtdeon. St Swr. 7/4s-A-1 2.u. - «. 7 1f- S I /j-r 7-7! C,ik
Sprinkling System
Heating, Final . MS" 9-22.--C9 - - SI
Plumbing Fixtures APS 4 -���
Final Gas Test 2c� /rlrJ _ D
Construction Pole
Underground Power
Rough Wiring i? , %J/-l"" I3/{bh vel),-,++fiin J:/c-e.) 7'-"/5"--- _S 9r-r
Trenches fT'-. Forms - Steel “,//>r/i 7 /
Floor Syste /
1 Reinforce Chimney Re-Rod
''!Vi Beam
allAthing
Frame and Flashing . ,y-7-!q _
Lathing, In Out ir CSA/ • -';/-I
Plaster, brown coat Rb5 L 9. F" i7
Plumbing Fixtures, Final ,'J4,' 51-2-5-4D
Electric Fixtures, Final (0 rj•7V
Building, Final nfl, /u 5 5v
OCCUPANCY I
Form 210-3M-4.57
I
-.e. E\,r.VWo
� ' ,;,H..- JUN 3 1959
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O.BOX 317 COSTA MESA,CALIFORNIA I iiNtIrl:CEDFP_
tit I, Y`Ci:. OCC:.
FOR APPLICANT TO TILL IN COMPLETELY APPLICATION FOR PERMIT
TYPE OR PRINT BUILDING
`R°ISS
ADD1621 Baker St.
COSTA MESA, CALIFORNIA TOR OFFICE USE ONLY
RECEIPT NO. I EERMIT NO.
OWNER COMPSR, Tne_ I C/'. —//
MAIL RE7`gJDBY. IDATE RECEIVED DATE ISSUED
ADDRESS 419 B. 17th St. I7y G.7:3=Jy
TEL BUILDING
CITY Costa Mesa Not-m.159 ADDRESS
ARCHITECT Carlson & LIC. COSTA MESA. CALIFORNIA
OR ENGINEER NO.
!aaalebrook FIRE . /
ADDRESS Garden Grnve ZONE Type- V Group J. f V
nn��yy9p Cole rove Inc. STATE 167293 APPROVED
CONTKXCTO g LIC.NO. BY DATE
ADDRESS 419 E. 17th St. , Costa Mesa' ZONING
DESCRIPTION No. g9 BLOCK T r !K\ PLAN/�B//��/!/�/� BUILDING
APPROVED /�`/e""% //_//
A.P.NO. BY l/ DATE /O J`%
SIZE 1 NO.OF BLOCS. YARDS EVES
OF LOT .•S NOW ON LOT ..._ REQUIRED - ALLOWED
USE OF (CENTER LINE ST.
EXISTING BLDG. none FRONT V FT. IN.
SETBACK LINE FROM
CENTER OF STREET 661 REAR YARD 281 R.SIDE ,(
\� FT. IN.
SIDE YARD I LEFT 5' I RIGHT r
5 L.SIDE IN.
DESCRIPTION OF WORK
REAR ‘It /}. FT. IN.
NEW I II ALTERATION I II ADDITION I
REPAIR I II MOVING I II DEMOLISH I
BUILSIZE 1365
NO.OF
1365 ROOMS 6 STORIES 1
EXTERIOR WA ROOF
COVERING 0tucc0 I COVERING Rock
USE OF BUILDING AND WORK TO BE PERFORMED
Single family residence with
attached double garage. plan
110C
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM. PURPOSE OF ESTABLISHING A PERMIT FEE ONLY.
PLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING
BUILDING CONSTRUCTION.. VALUATION
SIGNATURE OF�✓� L PERMIT FEE $']2.�
PERM ITTEEl
$ PLAN CHECK $16.00
AUTHORIZED AGENT Dike & Colegrove, Inc. 131TOTAL TOTAL FEE $ .00