HomeMy WebLinkAbout1082 MISSION DR - Building PermitsApplicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations
CITY OF COSTA MESA,
CONSTRUCTION PERMIT
PE MIT. NO.
�- 7/
TRACT NO.
LOT NO..
BLDG.
-
7493 I'.7/
Applicant's Mailing Address U •� - ��/ `S'r/ G"�, �'
Project Address •-'$C�•� /
Owner's Name G % vT�it: Phone jl�Z5l�
TYPE OF CONSTRUCTION ;
❑ CONVERSION ❑ DEMOLISH
DESCRIPTION OF WORK
NEW LJAOo LJ ALTERATION LJ REPAIR
❑ OTHER
-
~
ZONING
Address '�' �7L'La"�-'w" lule
TYPE OF PERMIT Ll GRADING - 0 FOUNDATIONS STRUCTURAL
❑ TENANT ❑ ELECTRICAL ❑ PLUMBING ❑,MECHANICAL , -
0,9THER -
PROJECT DESCRIPTION SO. FT. OCCUPANCY'
CO N STRUCTION TYPE VALUATION$
- _
ZON€ GRADING CU. YDS. (ACRES
, '
-
A. P. Ms
ZONE
.
Arch/Eng. - License No.
Address - -
PLNG. REF.,* BUILDING
TO BUILDING REAR YARD (TO P/U
PROPERTY INE
/1.
COntractor's Nem q�"� �" �'-`�'s'�Ph^^^
Address (me'I'ng)-X LU..�n7.f OKn,� _r'�.c�1�
�)�7"�
License No. 7"�.'
fCEFT SIDE YARD RIGHT SIDE YARD
-
PKG. SPACE REO. PROVIDED
_
LICENSED CONTRACTOR DECLARATION
I hereby affirm that 1 am licensed under provisions of Charter 9 (commencing
with section 7000) of Division 3 of the Business and Professions Code, and
Remarks: I -
I _ I
STREET WIDTH
PARK FEE $
1 ( `- 1
SPECIAL CONDITIONS:
my license Is In full force and s,MOct j/
Ucanze Class rise No. .11lU
Data ��3 Signature
WORKER 'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -Insure or a certificate
Workers' Compensation Insurance, or a certifietlic py thereof (Section
Lab. C.) c
cillo//
y No. Company
tilled copy IS hereby furnished.
Certii ed.cip I; filed with the city Bun Ing sl _
C//M Applicant I
EXEMPT( N FROM WORKERS' COMPENSATION DECLARATION -
(Thisseclion 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 subject.to the
Workers' Compensation Laws of California.
Signature
i ,
PLUMBING _
-
-
ATE "�/d �j BY
Bar Sink - Sewer Cap- -
--
- ELECTRICAL
-' BackflowPleventer _ Sewer Connection'
-
Automatic Washer Meter Omer 100 amps ,
- -
� Backflow Irrigation Solar Collectors
-
Construction Pole Sub Panel
Bathtubs, Solar Piping
Cooking Unit Sub Pole ,
Clarifiers Solar Tank
Dishwasher Motors 00-1 HP 01%-8Data
Dishwasher . Swimming PORI w/Spa
Dryers ❑Gas ❑Electric ❑9-15 HP ❑76-15+
_
Drinking Fountains Urinal
Fan Microwave
Microwave
- -
Floor Drains water Gosset
F.A.U. Pole Light
-
Date
NOTICE: If, after making this declaration. you should become subject to the
Workers' Compensation provisions,of the Labor Code, you must forthwith
comply with such pro0slons; or this permit 'shall be revoked.
Floor Sinks - -
Water Heater • - i
Fixtures
Range -
_
Gas Service. Outlets
Water Service -
DiB
Device
Sign,
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 _(Section 3097 Clv: C.)
Lender's Name' _
Interceptors I
-
L
Outlets
-
.Standing Sections 1
Kitchen Sink
- -
Switches
Trash Compactor
Lender's Address-
OWNER.BUILDER DECLARATIONLavatories
I hereby affirm that I am -exempt from the -Contractor's License Law for the
following reason,(Section 7031.5' Business and Professional 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/she is licensed pursuant to the provisions of
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
therefrom and the basis for the alleged exemption. Any. violation'of Section
7,•4s-.�5 byany applicant for'_a permit subjects the applicant to a civil
of not more than five hundred dollars $500 i
1 .Y ( I--,
owner of the property or my employees with wades as their sole
com pensaUon' will . do the work, and the structuretis not Intended or offered
for sale (Section 7044, Business and, Professional Code: The Contractor's
License Law does not apply to an owner of a property who builds or Improves
thereon, and who does such work himself/herself or through his or her own
employyees, provload that such Improvements are, not Intend" or 0 fared for
sale. If, However, the but ltl Ing or Improvement iss01tl within one year of com-
pletlon, the owner will have the burden of proving he/she did not bulid or Im- I
rove for the purpose of sale).
LJ 1, as owner of the property, am exclusively contracting with licensed con-
tract ors to construct the project (Section 7044,.eusiness.ano Professions Code:.'
The Contractors License Law does not apply to an owner of property wh0
builds or Improves thereon, and who contracts for such projects with a con-
tractor(s) license pursuant to the Contractor's License Law).$
❑ I am exempt under Sactlon ' B. & P. C. for this reason
_
Garbage Disposal
- -
P -.Trap.
p.
Generator 00-5 KW 115-15 KW
-
Roof Drains ,
Transformer ❑75-50 KW
❑5U+ KW -
- Reinspection Fee §75
- - 1 pain coon Fee
Showers - ! spa $15
- :_
Service Sink I I Issue Fee - $ 3
Meter ❑up to 100 amps -taus Fee $ 3
_ _ass
Zoning Approved BY Date
Application Approved By Date
Application Issued BY Date
_ MECHANICAL
Boiler -- Refrigeration System
putt - Under Ground 00-100,000 BTU 0700,000 BTU
..
BUILDING PERMIT $
PLAN CHECK $
-PLUMBING $
.PLAN CHECK
ELECTRICAL $
PLAN CHECK' $'
MECHANICAL $
PIAN CHECK $
, SUMMARY OF FEES
' $MIP -
_,,,eG^_ PERMIT
ISSUANCE
GRADING I
MICROFILM
TOTAL FEE' '
LESS
ADVANCED PC
FINAL FEE
$ 1
$
$
$
$ ; '
$
I
$
$
Duct -Structural System Repair/Alteration
-
,
Duct -Ventilating _ _
Exhaust System ❑ Multiple ❑
Firepl/Fact. BIL ICBO -
Date owner i
I hereby cc' 11 have rgae this application and state that the above -
Information is correct. I agrea.to comply with all city and county ordinances
and state laws relatin to building construction, and hereby authorize repre-
sentatives oY th15= sty M Meru on the above-mentioned properly for
Inspection purposes / ' ''n_ l I
Signature � / ���--�`�`�—� Date z9
Drivers' Uceose or SS 4s �
- Accounting; Goldenrod -Assessor
T;.
Q) JCONSTF;,UCTION,-AND'PLANNING� a
•7. "
' '- :' :
i, - ' _- POOL-& F^^ - -- -
-
- ' r r - -
} :APPROVALS _ P.ermrt`#
_ .te
-
;I rispeetor
-' :.
- "
',APPROVALS Permi..,-
Date
Inspector
-
..UI� i 'urn-:
`
,
_
-
1-. Temporary Electrical Service cr_(Pole ^
a ;
^
t ° _ '
',52'i Pool & Egwpmenf Location
I
T' 2? Soil Pipe-Undrgrrid ' �n u
530 Steel Rein-forcement -
` •.
i
°>
n , r
,
W Electrical Conduit Utility Uridrgrnd. -_j
`: ' ;-
°'T
�5A^ Forms'
I
Electrical Conduit-Undrgrrid'� �'
T.° °
55= Electric�l•Bonding
r4'
.�
5. Steel Reinforcement, ' �� `- �- - '.: '�
n'J _
'_ i `, :
`� ^ _
:'56. •Rough' Plumbing &Pressure Test
6. 'Electrical UF6R Grnd.l
`
57? APPROVAL TO:COVER-GUNITE
7. Footin s i s %.'
g
'
-
_
'`-58T
,
__Ie&ricaFConduit=Undramd._
8. Fountlatiori _ I
Gas Pipe,70-.Uni rgrnd., Test
9. Water, Pipe-Undrgrnd. I
'60. Backwash Lines,;P-Trap, O Undrgrnd.
,
10. Structural Floor System I �`rj q
�� 1i
'. 61. APPROVA'L`T0 DECK -- -
-
11. Property Sewed Line'& House Connection62.
Backwash.&-Receptor-Final
n -
12_63.
Heater & ;Vent-Final,
1;
F64. Plumbing System:Final•'
65. Electrical''-Final=
T
i i ' I
66TSo15r System-Final-'- '- -
-
67aFencing SFAccess'Approval
-
-
APPROVED FOR PLASTERING
I 1 r I =
POOL/ SYSTEMS FINAL
'69.!S
FIRE DEPT.' REQUIREMENT
-
APPROVALS Permit'#
I ,
' !
I
(
70.' Underground Hydro
171.i Product Piping O Gas ❑ Oil -
72.I Undeiground Flush'
-1
7.3.1 Urideigrrid. Storage Tank ❑ Gas _0 Oil
' " I
' X74.1 Overhead Hydro
75.1 Dry Chemical-
'i
I 76. Dry Standpipe
1 I
177., FIXED SYSTEM-FINAL
j
I !
I
1781 FI REPMEV. FINAL '
i
,
'Notes: i
I I
_
I�
J.
Vr•
Imo;
j-I
38. Final Plumbing
39. Water Service-Finale
a d I
40. Gas Service-Final
41. Solar Domestic-Final
J_
42. Backflow Preventer i If-• -::
i I
I ' '
_
_
43. Backflow; Irrigations y l r'
=
!.' u
o• I 1 -
• °
II�If i I S
44. Landscape Irrigation Sy"stem :;
to �t,�
'-
,
"'
-
-
�' ;r
,!,A ;_ � ••i
45. Sound 'Attenuation
.�.
ice,
._
, .�; -
HAY r:' 1
46. Hand' eap;Re. -1 .. I �,; •- t
i ;
47. FINAL' STRUdfURE & BUILDING;'
i '
n i-
48. Special Requirements Cornple`ted-
n
_
49. Electric Releaseto 'Edison � �,
i _I
-1 -
I
--t - -
t
{-- -
i-
50. Gas Release it to Southern Califorrria Gas Co
I
x i i i
i
I
1
51. CERTIFICATE;OFOCCUPANCY
!_-T
i._,_
L__;_
1 _lam-_+
No r r i i Date
I i
..
Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. _
CITY OF COSTA MESA PERry�T N TRACTNO. LOT NO. 7304 10/ 14/32:
CONSTRUCTION PERMIT /� /// I .
Applicant's Mailing
Project Address
Owner's Nam//e`�
Address /
44 Arch/Eng.
'' \ Add
A )Contrxtor's Names
�f"'chess (mailing) —
J ADD
OTHER
LJ ALTERATION LJ REPAIR
1 FOUNDATION LJ STRUCTURAL
PLUMBING 1:1 MECHANICAL
V PROJECT DESCRIPTION SG. FT. OCCUPANCY
CO N STRUCTION TYPE VALUATION $_
ZONE GRADINGCU.YDS. ACRES_
Eft ENSED CONTRACTOR DECLARATION I Remarks:
L hereby affirm that 1 am licensed under provisions of Charter 9 (commencing
with section 7000) of Division 3 of the Business and Prolassions Code, and
my license Is In full force and effect_s�J(? .tea/
LicenseCG- 5t1•No. / e
Data U Signature -fY
WORKERS" COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self -Insure or a certificate
Workers' compensation Insurance, or a certl(I y the(eof on
�Iicy No- Company
Certl copy Is hereby furnished. (��
fled <p y filed with the nty,Building DI slo
Date Applicant
EXEMPTION FROM WORKERS' COMPENSATION DECLARATION
(Thisaction need not be completed If the permit Is for one hundred ($100) or
less). '
1 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.
Date Signature
NOTICE: If, after making this declaration. you should became subject to the
Workers' Compensation provisions Of the Labor 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 theperformance
of the work for which this permit Is Issued (Section 3097 Civ. C.)
Lender's Name
Lender's Address -
OWNER BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License law for the
Section B. & P. C. for this reason
I
Data Owner'
above
lances
repro• -
v /or
Showers
Service Sink: -
3oiler -
Duct - UnderGround
Duct -Structural
Duct -, Ventilating -
Exhaust System 0 Multiple
Firepl/Fact. Bit. ICBG #
Heating System &Ducting
E)4100,000,BTU 0
Sink
kflow Preventer
kflow Irrigation
Dishwasher
Drinking Fountains
Floor Drains
Floor Sinks
Gas Serv
ice Outlets
Interceptors
Lavatories
Hoof -Drains
urvlswn -e or me eusness ono woressions wadi, or ma[, ne sne Is exempt
7t ere/rom -and the bails for the allegetl exemption: Any viola Ion of Section
:')1.5 by -many applicant for a'permlt subjects the applicant to a civil
' j7nity of not more than five hundred dollars ($500). I
,- '
.'I, az owner of the 1proparty or my employees with wages as [hair sole ,
compensation will do the work, and the structure is not intended or offered
for ale (Sec/(on 7044', Business and' Professional. Code: The -Contractor's
Licence Law does not apply to'an owner o/ a property who builds or Improves .
thereon, and who does such work himself/herself or through his or her own
employees, provided that Such Improvements are not Intended or offered for '
sale. If, however, the building or Improvement Is solo within one year of com-
pletion
om- (
pletlon, the owner will have the burden of proving he/she tlld not build or Im-
rove for the purpose of�sale)�
1, as owner o/ the property, am exclusively contracting with licensed con-
tractors to construct the project (Section 7044, Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who I
builds or improves thereon, and who contracts for such projects with acon-
iractor(s) license pursuant to the Contractor's License Law).
❑ I am exempt under
100,000
Hood or Type I
Drivers' Licence or SS 11 I I Registers
CMF 0865-46 rev. 12/82 White - Building; Canary -Applicant: Pink -Accounting; Goldenrod - Assessor
t TYPE OF CONSTRUCTION LI NF
i ❑CONVERSION ❑DEMOLISH
hone ��7f1� DESCRIPTION OF WORK
TYPE OF PERMIT GRADING
NO. ❑TENANT 1:1 ELECTRICAL
❑, OTHER
A. P. sY•
PLNG. REF.
LEFT SIDE YARD
PKG. SPACE REO.
STREET WIDTH
SPECIAL CONDIT
REAR YARD (TO P/U
RIGHT SIDE YARD
PROVIDED
PARK FEE'S
g LJ
Sewer Cap - ELECTRICAL
-
Sewer Connection Automatic Washer. Meter over 100 amps
Soler Collectors Construction Pole Sub Panel
Solar Piping Cooking Unit Sub Pole •
Solar Tank Dishwasher Motors 110-1 HP 01X$
Swimming Pool w/Spa Dryers ❑Gas ❑Electric Inc.Solar 09-15HP 016-15+ •
Urinal '
Fan Microwave
•
Water Closet' F.A.U. Pole Light 1
- Water Heater Fixtures Range _ -
WaterService Device Boxes Sign
Outlets Standing Sections
Switches Trash Compactor '
Garbage Disposal
- Generator 00-5 KW 05-15 KW
- Transformer X15-50 KW t ,
' ❑5U+KW; Reinspection Fee $15 LESS
''
Reinspection:Fee "$15
Meter ❑up to 100 amps Issue Fee $ 3
Issue Fee ,, l 1 $ 3 Zoning Approved By Date
MECHANICAL Application Approved By (Date ./ •p
Refrigeration System Application Issued By ' Data /� •/T_ � a3
❑0-100,0008TU 0100,000 BTU I SUMMARY OF FEES
System Repair/Alteration � BUILDING PERMIT $ SMIP $
_ PLAN CHECK PERMIT
PLUMBING ISSUANCE ' $
' PLAN CHECK' $ GRADING $
ELECTRICAL, $ i $
'
PLAN CHECK $ MICROFILM i $ I
' MECHANICAL $ TOTAL FEE' $ ;
Reinspection Fee. $15 PLAN
CHECK $ ADVANCED PC
FINAL FEE
$
$
� `�
Issue Fee
$ 3
w
' CONSTRUCTION AND ;•('; NNING• ' - ,
C •'
'
. -
- : -
- - ' " POOL.&
�'ApPROVALS
APPROVALS `- Permit# ri ,; e a
_Rate -
inspector
Permit#
=Date
Inspector
r jk. Temporary Electrical Servideor-EPole ::
`• "
�'
527 Pool &.uipment Location,,,, -
-
•
-
-
W" 21 'Soil Pipe-Undrgrr'd=._--": ' n
'y r
r '�
53' Steel Reinfordement _
3' ElectricaI'Conduit Utility-Undrgrndi i ��
_
;-,
54.1 Forms
-
4! Electrical Conduit-Undrgrnd,�,.x:55
Electri6B'ding -
-
5: 3teef,Reinforcement I r,-
1
u ;
Rough Plumbing & Pressure Test
'
'-'
6. Electrical UFER Grnd.l . ;; - J ,
_56
�. - "
57, APPROVAL TO COVER-GUNITE_ -
_ -
,
7. Footings I I- .1 o °
- _
�'' _
. 5§ Electrical Conduit-Undrarn i.--
I
8. Foundation-
'-
59. Gas Pipe, O-Undrgrnd:; Test=
9. Water Pipe-Undrgrnd. i u _
�,, _
•',60. Backwash Lines, P -Trap, O Undrgrnd.:•
10. Structural Floor System
!,61. A'PPROVALTO DECK --
11. Property Sewer Line & House+Connection
cx.62.
Backwash �& Receptor -Final
':
_
12. Sewer Cap' i ' - I • ;1 r- I
,-
-ia `
;• 63. Heater &Vent -Final -
-
-
13. Roof Drains 1G
Plumbing.System=Final'
14. Rough Plumbing:•.65.
Electrical -Final •- - -
•'15' Rough'Electrical=Conduit'1- X77-71
-T-! - -r-
I
66.; Solar System:Final-
16. Rough Electric Wiring, •- { i 1 i,m 6
j :,
(� I•
67.• Fencing &Access Approval --r-
1 �Rf&�
17.Rough Wiring Signs N ; !!"' j
= !.,,68.:
APPROVED FOR PLASTERING'
18: Rough Electric Il TBA, Ceiling !,
' I I I69.
POOL/SPA SYSTEMS FINAL
.. 1
19:,rRough Heating &'Air Conditioning
FIRE DEPT, REQUIREMENT•
_
_
APPROVALS{ Peimit
20. (Rough Factory Firephce, i n �I
I
21. ;Ducts• -in Stru�turle•: i { 1 [
(
I
70.' Underground Hydro I
-
-22. 'Ducts, Ventilating F
71.E Product Piping bGas ❑Oil
23. �Gas'PiPe-Rough &'fest 3 ! j T rr� -
� � -�
'-"-�- -',
72.1 Underground Flush
-
.I -24. Roof Framing '+ {I �I '
, I r, 1 . ; .,
., • 1
73.' Under rnd. Storage Tank b Gas ❑ Oil
25. Roof SheatFiirig r ! �i.,'1 •
. �, _
' 104.
Overhead Hydro
1! -26. 'T -Ba Ceiling (Struciuralj, & Monocoat4 I
{ z.,
�'-;
75.1 Dry Chemical
-
r: 1 1 i. I
•- I
1
1
'.27. Frame and Flashing I ; �J !, {
'.' ' +
:; I
76.' Dry Standpipett -
28. Lathing &-Siding I n I{
I_
X77.1 FIXED SYSTEM •,
it
-FINAL -
M 29. Insulation j "' r + I '�
I
I
78.' FPRE PREV,. FINAL
I
30. Drywall Nailing "•
I '
+
!Notesa ! '
,r'
31. Plaster Brown Coat j
11
:,'§2. BectricaI Power MeteriFinal I li
33. 'Final Electric j ( i' !
I II
L.
34. Final Heating &!Air Conditioning
"
_i�l..
��'r•'"
'-''
35. Final Gas! Pipe-Testi^ I `'i
I (
r� l^ -
I C
�'' 'T
- ,-
I I- 9 r' T •r
I
- _
36. Hood orCa noPY" ; °
37. Final Factory Fireplaces i '- 1 ,• it
38. Final Plumbing 1 1 •
7�jy/,_jf
LFcf% 1
'
1 _��
1 _
39. Water Service -Final. ;
40. Gas Serviee-Final
t , I I I I I I it I
41. Solar Domestic -Final
42. Backflow,Preventer�
-r
i
43. Backflow Ir'rigatioh' ? r_
I :?' "= 7
_ ; i
-", '•
1 i
.
44. Landscape Irrigationi"5ystem
45. SoundyAttenuation.
46. HandicaplRegulations I^ I { i( _
�'•
"'
I 1 - -
47. FINAL STRUCTURE&BfUILDINGe
48. Special RequirementsCompletedj
1 I''I
-
49. Electric Releaseito Edisonj
I
50. Gas Release to Southern California Gas Co
51. CERTIFICATE OF
!
OCCUPANCY 00
l l l
Da
5355 Lot 44, Tract
COSTA MESA BUILDING -SAFETY DEPARTMENT
P. O. BOX 317 COSTA MESA. CALIFORNIA
gkE RE3CQVEP ED61
FINANCE DEPT.
CITY OF COSTA IV10A
For Applicant to Fill In Completely
APPLICATION FOR PERMIT
TYPE OR PRINT
BUILDING
BUILDING
ADDRESS 1082 Mission Drive
For Office Use Only
COSTA MESA. CALIFORNIA
RECEIPT NO. P2RMlT'NOr e.
OWNER a a v Co.-g-�0J,j
MAIL
REC81 O BY DA RETE ISSUED.
I"�
ADDRESS O a t Highway-GBIVl&
SO
TEL
Corona del Mar Calif. OR 422
BUILDINGADDRESS
CITY NO.
ARCHITECT iEL.
OR ENGINEER Macco CgrngirationNO.
COSTA MESA. CALIFORNIA
ADDRESS 1800 E. Coast Highway
FIRE In/U"r�
ZONE TYPE GROUP t /
CONTRACTOR
APPROVED
BY DATE
ADDRESS 3800 E. Coast Highway
ZONING
CITY C G a
ZON r J I NO. OF I U86 OP N Vt
I BUILDING 1 J
/
STA
LIC. op NO.
-}PL/A-NSB
DEBCRIPTIOx 1 �1L_ L -1— (/ Zh
SIZE NO. OF SLOGS.
I
OF LOT NOW ON LOT
A. P. NO.
USE OF none
EXISTING BLDG
YARDS EVES
APPROVED ALLOWED
SETBACK LINE PROM
1 11
(CENTER LINE ST. 1 _
�//
CENTER OF STREET 11 REAR YARD
FRONT FT. IN.
SIDE YARD I LEFT 61
I RIGHT 61
R. SIDE 40 FT. —^ IN.
DESCRIPTION OF WORK_
�
L. SIDE FT. IN.
NEW IXXI ALTERATION I II ADDITION
REAR FT. 45�' IN.
REPAIR I MOVING I DEMOLISH
APPROVED �/� DATE
1
BUILDING O1X 1611 NO. OF
S ROOMS STORIES 1
EXTERIOR WALL ROOF
COVERING Stucco COVERING CO'T'P-
USE OF BUILDING AND WORK TO BE PERFORMED
Garage area 476 S F
w/attached garage
Covered Porch area 38S F
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
THE AMOUNT SHOWN UNDER VALUATION 18 FOR THE
AND STATE THAT THE ABOVE IH CORRECT AND AGREE TO COM.
PURPOSE OF ESTABLISHING A PERMIT FEE ONLY.
PLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING
VALUATION
BUILDING CONSTRUCTION.
SIGNATURE OF
PERMIT FEE S
Q�
PLAN CHECK S /V �
PERMITTEE
C ,
s 16,086.00
'', '�'i'L'�"LG
AUTHORIZED ADEN I.
5h,00
TOTAL FEE s