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Home My WebLink About3230 MONTANA AVE - Building Permits(714) 754-5273 • Fan (714) 754-4856 • wwv+.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3230 MONTANA AV Suite No Vicinity: Parcel Nunmber: 13909104 Applicant: SZABO, KEVIN,•:� � Address: 2737 S CRODDY'% STED� � SANTA ANA, CA -�, i . � . . Owner: THOMAS, JANET J Address 3230 MONTANA -" � , COSTA MESA, CA PLUMBING PERMIT � Phone: (714)241-1414"� , � Zip: 92704. . , Phone: Zip: � �92626 a Status: � ISSUED Applied: 04/09/2002 Issued: 04/09/2002 ISSUED BY: � ' _ „� �. � � �� . . �� Contractor: COAST ROO7ER PLUMBING HEATING & AIR CONDITIONING Address: 2737 S CRODDY - � � - . � STE D . � � Phone: (714)241-1414 -� � � SANTA ANA. CA Zip: 92704 . � License: 529127 Arch / Eng : Address: . . �� , _ : . . - -- . Phane: � � �. Zip:� , � , --�-- -- licensei � . : �j" - ' SCOPE OF PERMIT REPLACE WATER HEATER - -- , � ;'FEE SUMMARY , � � AMT;' QTY ' � AMT�' QTY "��'�� . %AMT QTY ISSUE FEE � � . � ' $23.50�� r t ^+;-� s- Laundry Tub / Washer .' . $0.00 �� 0 c: ;'��',�� Sump Pump , ' ` , �$0.00 0 Backflow irrigafion $0.00 � 0� Landscape Irrigation �$0.00 0 Swiinming P.00l ,$0.00 0 Backflow Preventer � $0.00 0 � � � P-Trap �;� $0.00 0 Trap Pnmer - ; - $0.00 0 Bathtub � � '�$0.00 - .0 �`� � Pressure Re9ulator ' $0.00 0 � �� Urinal - ' � ' $0.00 0 Clarifier System �$0.00 0 - Process Piping (per 10 ft)' $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0 Connect pce,Soda,etc) '$0.00 0 � Receptors ' $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units ��$0.00 � 0= �� Septic Tank $0.00 0 Wash Basin �� $0.00 0 Dishwasher $0.00 0 � Sewer Cap for Demo $0.00 0- Wash Basin Set $0.00 0 Drain, Floor $0.00 0 Sewer Connect $0.00 0� Waste and Vent System $0.00 0 Drain, Rainwater $0.00 0�-� � Sewer Private Line - $0.00 0 � Water Closet (Toilet) $0.00 0 Drain,Roof $0.00 �0��.-. - , Shower' .. . ... ..$0.00 0 WaterHeater/vent $12.30 1 Drinking Fountain $0.00 0 � Sink, bar $0.00 0 � Water Piping Qnst or RepJ $0.00 0 Expansion Tank $0.00 0 - Sink, commercial -� �$0.00 " 0� Water Re-pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink, Floor $0.00 0 Water Service $0.00 0 Gas (1-4 outlets) $0.00 0 Sink, kitchen $0.00 0 Water Softener $0.00 0 Gas (Over 4 outlets) $0.00 0 Sink, service/mop $0.00 0 OTHER $0.00 Gas Repipe $0.00 0 Spa (priva[e) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa (public) $0.00 0 PLAN CHECK $0.00 Interceptors (Grease, Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors (Sand Auto ) $0.00 0 TOTAL CALCULATED FEES: $35.80 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 permil to be considered Iegai, such work must comply with all applicable codes, and all required Inepections and final epproval must be obtained. Failure to obtain inspections and final approval will result in the ezpiration of ihis permit. �, FOR INSPECTIONS CALL: (714) 754562B YLr.!T.rYIYIC�II WORKERS' COMPENSATION DECLARATION: I hereby eifirm untler penalty of perjury one of ihe following declarations: ❑ I have antl will malntein a certificeta of consent to self-Insure for workers' compensatlon, as provided tor by section 3700 oi ihe Labor Code, for ihe pertortnence of Ihe work for which this permit is issuea. �I,have antl will maintain workers' compensaUon insurence, as requireG by sectlon 3700 ot ihe Labor Code, for the pedortnance of the work for which this pertnit Is Issued. y w ers' compensation Insurance cartler and policy number are: 1 I 1 �arrier; rJtT' � FU t-1p P�Iicy,Number. I b, LO Z� h�2�O�L� rs section need nat be campleted i/ the permit is valueU et ane hundretl dollars ($100J or less.) �-'-= "n� ' ' ❑ I cetlity that in the edo ance of th c r which this pertnit is issued, I shall not employ any person in any manner so as ro �ecome subject to the workers' compensation laws t alitoryja, an egree het if I should become subject to ihe workers' compensation provislons of Section 3700 of Ihe Lebor Cotle, I shall forihwith comply with Ihese p isions. /� pplica� Ign'etu�e: .:.Date:�� -1 r � 1^ WRANING: FAIWRE TO SECURE OR RS' NSATIIXJ COVEPAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOVER TO CRIMINAL PENPLTIES AND CIVIL FWES UP TOONE HUNORED TFiOUSAND DOLLARE ($100,000), IN AODRIIXJ TO iHE COST OF COMPENSATION, OAMAGES A$ PROVIDED FOR IN $ECTIqJ 3106 OF THE LABOR CODE, IMEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby effirm ihat I�am f�nd eH�.'Lic: k _ Cont�s SignaWre: of Chapter 9(commencing with Section 7000) of Oivision 3 of Ihe Buslness and Pmfessions Cotle, and my license is in full �'.q. �,.' � L � �7ate:. y' '(J %- CONSTRUCTION LENDING AGENCY: ❑ 1 hereby aMirtn that Ihere is a consiruction lending agency For Ihe peAormance of ihe work br w�ich ihis permit is issued. (Sec. 3097, Civil Code). Lendefs Name: Lendefs Address: SignaNre: Date: OWNER-BUILOER OECLARATIONS: I hereby affirm that under penalry of perjury that I am EXEMP7 FROM 7HE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business antl Professions Code: Any city or county which requires a permit to constmct, alter, improve, demolish, or repair any structure, pnor to its issuance, elso requires ihe applicaN tor such pertnit to file a signad statement Ihet he or she Is Ilcensed pursuent to the provisions of the Conirectors License Law (Chepter 9(commencing with Sedlon 7000) of Divislon 3 of t�e Business end Professions Cotle) or thet he or she is exempt therefrom and the besis for the alleged exemption. Any vlolation of Section 7031.5 by any applicant tor e permlt sublects the applicant to a civil penelry of no� more than five hundred tlollers ($500).): ❑ I, as owner of Ne property, or my employees with wages as �heir sole compensation, WILL DO THE WORK, and Ihe structure Is no� intended or otfered tor sale (Sec. 7044, Business and Professions Code: The Coniractors Licensa Law does not apply to an owner ol property who builds or improves Ihereon, and who does such work himsel� or herself or Ihrough his or her own employees, provided Ihet such improvements ere not intended or oflered for saie. If, however, tha building or improvement is sold within one year ot completion, ihe ownervhuilder will have the burden of proving ihat he or she did not builtl or improve for purposa of sele.). 0 I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Cotle: The coniractors Licensa Law does no� apO�Y �o an owner of pmperty who hullds or impmves iherean, and who contracis for such pmject with a conlwctor(s) license pursuant to the Coniractors License Laws.). ❑ I am exempt under sec. Business antl Protessions Code for this reason: Signature: Date: Owner ID ventied by dnver's licen5e. ❑ Ves ❑ No Driver's License No. Expires: Venfication oi Ownership by (rype of documen�, i.e. - property tax 6ill or deed): DIVISION OF INDUSTRIAL SAFETV PERMIT CERTIFICATION: ❑ I hereby certity ihat no excavation five (5) or more feet in tlep�h into w�ich a person is required to descend, will be made in connection with work euthorized by Ihis permil, antl ihat no building siructure, scattolding, falsework, or tlemolition or dismantling ihereof, will be more ihan thirty-six (36) feet high. (Chap. 32, Gry 2, Art 2, Sec. 341, Ttle 8, Califomia Administrativa Code). ❑ As owner-builder, I will not employ enyone to do work which would require e permil from tha Division of Indusinal Safety, es noted above, unless such person hes e pertnit ta do such work irom ihe division. Signature: Date: Division of Intlusinal Safety Permit Number: CERTiFlCATE OF COMPLIANCE AND AUTHORVATiON OF ENiAY: I certity under penalry of perjury thal 1 have reaa this applicetion and stale lhet ihe iniortnalion given is correct I egree to comply wi�h all stete laws end city ortlinances releting to builtling consiruction, end authorize represeniatives of Iha Ciry ot Coste Mesa to enter uDon �he above-described pryperty tor inspection purposes. I eqree not to occupy or altow occupency of any building authorized by Ihis parmit unlil final inspection. cooe i. 1616 1266 200 Fixed System Finel Fira Prevention Paol Spe Finel Finel Re-Roof 201 Flnel Block/Retelning Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition PeI& UiI1IlA6,4 COOEt INSFECTIONTYPE 206 Final Machanical 208 Final Plumbing 210 Final Eleciricel 272 220 Final Fire Preventlon Final Planning Approval 222 Final Site 250 Final Building/Occupancy � P�IE I[�EL$ �-�1,-oa �'p� � �»a> >sa-sa�s • Fex (714) 754-4856 Job Address: Suite No Vic(nity: CITY OF COSTA MESA BUILDING DIVISION � DEVELOPMENT SERVICES DEPARTMENT PERMIT 3230 MONTANA AV HALLWAY Parcel Number: 13909�04 Applicant: THOMAS, JANET J Address: 3230 MONTANA COSTA MESA, CA Owner: THOMAS, JANET J Address: 3230 MONTANA Contractor: qddress: Arch/Eng: qddress: COSTA MESA, CA REMOVE AND REPLACE FAU. ISSUE FEE Inst FAU <100 k BTU Inst FAU >100 k BTU Repair / Alt Cooling/Heat Inst / Rep. Recess Wall Htr Refrig Sys �100 k BTU Refng Sys y100 k BTU Gas Piping Factory Fireplace Hood w/Mech Exhaust VAV Box Vent Fan / Single Duct Appliance Fire Dampers Smoke Dampers Inst or ReloGate Appl Vent Air Handlers < 10000cfm Air Handlers > 10000cfm Floor FurnaCR Floor or Suspend Heater $22.00 $1315 $0.00 $0.00 $0.00 $0.00 $0.00 $0.�0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Quantity 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 MECHANICAL PERMIT Phone: 714-545-7571 Zip: 92626 Phone: Zip: 92626 Phone: Zip: License: Phane: Zip: License: SCOPE OF PERMIT FEE SUMMARY PERMIT NUMBER� M99-00243 77 FAIR DRIVE, COSTA MESA, CA 92626 ISSUED BY: Repair / Alt Absorbtion Unit Repair / Alt Refrigeretion Unit Ventillation System Evaporative Cooler Commercial I ncinerator Domestic Incineretor Compressors / Absorolion Svstems Upto3hplt00k8TU 3 To 15 hp / 500 k B7U 15 To 30 hp / 1,000 k BTU 30 To 50 hp / 1,750 k BTU Over 50 hp / Over 1,750 BTU Boilers Upto3hp 3To15hp 15to30hp 30 to 50 hp Over 50 hp Olher Mechanical Fee Investigation Fee Plan Check Fee Reinspeclion Fee TOTAL CALCULATED FEES COMMENTS / SPECIAL CONDITIONS Status: ISSUED Applied: 05I20/1999 Issued: OS/20/1999 Quantity $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 so.00 so.00 $0.00 535.25 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92-28, § 1, 1241•92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a pariod ol 780 days. INSPECTIONS: In order for the work a�lhorized under this permit to be considered legal, such work must comply with all applicable codes, and all requlred Inepectiona end flnal epprovel must be obtained. Failure to obtain inspections and finaf approvel wi11 resutt in the expiration of this permit. FOR INSPECTIONS CALL: (774) 7545826 WQRKERS; COMPENSATION OECLAfiAT10N: _ I 4''ereby aitirtn under penelry of perjury one ol the tollowing tleclaratlons: � ❑ I heve end will maintain e cenificate of cnnsent to selt-Insure for workers' campensatlon, es provided for by sectlon 3700 at the Labor Code, for Ihe pertortnence of the work for which this permit is iuued. ❑ 1 �ave end will meintaln workers' compensation insurance, as required by seclion 3700 ot the Lebor Cotle, for the pedortnance of the work lor which this pertnit is issued. My workers' compense0on Insurence cerder end policy number ere: Carrier: Pollcy NumGer: ('rhis secHon need not be wmp/ete0 il the permit is velued et one hundred dollers ($f 00) or less.) ❑ I certity that in the pertortnence of t�e work For w�ich this permit is Issued, I shell�not employ any person In eny manner so as to become subject to the workers' campensetlon laws of Califomia, antl egrea that ii I should become subjeci to the workers' compenutlon proNslons of Section 3�00 of Ihe Labor Code, I shell forthwith comply wit� these provisions. Applicent Signeture: Dete: WARNINO: FAILURE TO SECURE WORKERS' COMPENSATION COVERAOE IS UNLAWFUL AND SHALL SU&IECT AN EMPLOVER TO CRIMINFL PENALTIES AND CIVIL FINES UP TO ONE HUNORED iMpW�'AND DOLViRE (810D,000� IN ADDI710N TO THE COS70F COMPENSATION, DAM4GES AS PFOVIDED FOR IN SECTIpN 3'Jpg OF THE UBOR CODE, IMEREST, ANO ATTORNEY'S FEES. LICENSED CONTRACTORS OECLARATON: I hereby ettirm Ihat I am licensetl under Drovisions of Chapler 9(commencing with Seciion 7000) ot �ivision 3 of iha Business entl Professlons Code, and my licensa is in full force end eHect. Lia a Class a Conirectors Signature: Date: CbNSTRUCTION LENDING AGENCY: ❑ I hereby eHirm Ihe� ihera Is a consimctlon lending egency for ihe pertormence ot ihe work for which this permit Is Issued. (Sec. 3097, Civll Code). Lentler's Neme: Lenders Address: SiBnature: Date: OWNER-BUILDER DECLARATONS: I hereby eHirtn Ihet under penal�y ot perjury Ihet I am E7fEMPT FROM THE CONTRACTORS LICENSE LAW tor ihe tollowing reason (Sac. 7031.5, Business entl Professions Cqde: Any city or counry which requires e permit to constmct, eltar, improve, tlemolish, or repalr eny structure, pdor to Its issuence, also requires Ihe flpplicent for such pertnit to tile e slgned statement that he ar she Is licensed pureuent to ihe provislons oi the Caniractors Llcensa Lew (Chapter 9(commencing with Sectlon 7000) of Dlvislan 3 ot t�e B�siness antl Pwfessions Code) ar thel he or she is exempt therefrom end ihe basis for the elle8ed exemptlon. Any Nolatlon oi Section 7W 1.5 by eny aDP�icant br a pertnit subjects the applicant to e ciWl penalry o1 no� more than tive hundred dollers ($500).): ❑ I, es ownar of the properry, or my employees with wages as their sole campensation, WILL DO 7HE WORK, end the siructure Is not Intentletl or oHered for sale (Sec. 7044, Business entl Prolessions Code: The Contrectors LJcense Lew does not epply lo en owner oi property who builds or improves thereon, end who does such work himselt ar hersetl ar �hrough his or her own employees, O�oNded Ihet such improvamenis are not intentled or oNeretl for sale. It, however, ihe bulltling or Improvement is soltl wlihin one year of comp(afion, the owner-builtler wili heva the burtlen of praving thet he or she did nof butltl or improve for purpose of sele.}. Q I, es owner oi the pmperty, em EXCWSIVELY CONiRACTING WITH LICENSED CONTRACTORS to construa Ihe pro�ect (Sec. 7044, 9usiness and Professions Code: 7Te conireciors Licensa Lew does not aDP�Y �o en owner ot property who builds or improves t�ereon, entl who contraqs for such pro�ect with e contrector(s) license pursuant to Ihe Contra�,[ors License Laws.). Business entl Protessions Cotle for this reeson: �ID ver�d by ddvers li�r(se. "�] Yes ❑ No Orivi cens Verification of Ownership by (type ot daument, i.e. - propeM �%� bill or deed): �� DIVISION OF INDUSTRIAL SAFETY PEpM1T CERTIFICATION: ❑ I hereby Cehify that no escaveilon tive (5) or mare teet In depih Into which e person is requlred to descend, will be matle in connectlon wlth work authorizetl by ihis permlt, end ihat no building strucNre, scafloltling, talsework, or demolitlon or dismantling t�ereof, wiil be more ihan thirty-sla (36) feet high, (Chap. 32, Gry 2, Art 2, Sec. 341, Title 8, Calilamla Adminisiretive Cotle). ❑ As owner�bullder, I will not employ enyone lo do work whlch would require a pertnit from the Division ol Indusirial Sefety, es notetl ebove, unless such person has e permil to do such work from the tlivision. Signawre: Date: Division af Industnal Sefery Permil Number. CERTIFICATE OF COMPLI4NCE AND AUTHORIZATON OF ENTHY: I cedity under penelry ol perjury that I heve read this epplication and stele that the intormation given Is Corr . agree to comply wlth ell stete lews end ciry ordinences relating to building construcllon, end aNhodze represen�atives of Ihe Ci�y of Costa Mesa to enter upon �he ove- scdbed Droperty i%� Insp�/e�y'6n or�p,ases. I agree not to occupy or ellow occupancy o/ eny huilding authoAzed by Ihls pert�nit �until fpina�l InspecUon. l � :4rl--rrTmY9� t �� dff'�7Z7 / / �g�� 5 ,�� v SOpE 1, INSPECTIONTYVE 1616 Fixed System Final Fire Preventlon 1266 200 20l 202 203 204 2msrs Pool Spe Final Finel Re-Roai Finel Block/Retaining Wall Finel Fectory Fire Plece Finel Sign Finel Demoli�ion �� J�$ £Qpf,j INSGECTONTYPE 208 Final Methanical 208 Final Plumbing 210 Final Electdwl 212 Final Fire Preventlon 220 Final Plenning Approvel . 222 Final Site 250 Final Bulltling/Occupency Date /2 6� S � OwtvER FR4NCIS, W. LEON •� JOB ADDR�SS 3230 Montana Ave. GENERAL CONTRACTOR AdN1Z'31 B].lt AP No.113-�0lF LOT TRACT INSPLCTIONS Signat c G� coat 0 PIRE 7.ONE DA1'E GROUP DATE 1'9'62 BUILDING PERD4IT DBSCRIPTION OF WORKBIOC TYPE ZON� R1 SULiCON7RACTOR i2] '� � ,'" ( 6 2 � C057A MESA BUILDING-SAFETY DEPARTMENT P. O. BO% 917 COBTA MHBA. CALIFORNIA For Applicanf fo Fill In Complefely TYPE OR PRINT BUILDING � _ ie. . — __ A ..� � ARCHITEC7 � STATE COSTA MESA. CALIFORNIA , LEo.J F�nN c i S .�i AiNF C o 9Tw MESA No: TEL. t NO. l4aH�RRL-1��T C�r fa-�4 w- `� ST. i�1Tr. � n� A . _ .. TEL. SIZE ��1 x /� OF LOT USE OF EXISTING BtDG� 6BTBACK LINB PHPM No. oP BLDGB. DESCRIPTION OF WORK BUILDING SIZE EXTERIOR WAL4 COVERING USE OF BUILDING AND fl I I �' v / I ./ . NO. OF ROOMS STOF ROOF COVERING RK TO HE PERFORMED (aMMUU�T� ! _ � �EE RECEIlIED ��AN 10 �962 . FINANCE �DEPT. APPLICATIOFJTFO�RFPERIviR �ESA BUILDING For Office Use Only RECEIVT NO. P�1�11j�1,0� /L �� SY I DAT� NE�iiVESY� % T= I�U[� i v tn BUILD COSTA MESA, CALIFORNIA FIRE ZONING zowe NO. OP uee oF ruew B oc n�( I PLAN9 z BUILD�NO �ea�� G d` 36 7R 3`f o 3 DEBCRIPTION A. P. N O. I I� — V �� / YARDS EVES APPROVED ALLOWED ICENTHR LINE BT.) FRONT �FT. � APPROVED �� FT. IN. O FT. IN. �,(9.,.. „erF //9��z � HEflEBY ACKNOW��GB TN�T I HAV6 RBAD TN19 MPYGTION TH6 AMOUM BXOWN UNOeN VALUATION IB IOR TH8 ww0 eTATe THAT �H6 AOOV[ 19 CONR6CT �ND AGPEB TO COM- PUPP08E OP ¢BTA0U8HING A PERWT F(E ONIY. PLY WITH ALL C�TY OFDINANCEB AND HT�TB W9 RH6ULATNO am�oma CorvoTAURION. VAWATION / BIGNATURH OP „� � PERMIT FEE $ W PERMITfE Y S /� /' PLAN CHECK $ AUTHORIZED AGENT .r-. TOTAL FEE Lor 36 - rR 3403 *. �' 2�?'��5 COSTA MESA BUILDING-SAFETY DEPARTMENT P. O. BOX 917 COBTA MEBA. CALIFORNIA For Applicanf fo Fill In Completely TYPE OR PRINT BUILDING 'Z O MONTANA AVENUE ADDRESS COSTA MESA. CALIFORNIA ■ ARCHITECT ■ STATE �555 PLACEN7IA QVENUE TEL. �R K.W, KOLL CONSTRUCiION CO.�I GWaRovE BY �555 PLACEN7IA QVENUE NEWPORT BEAGH� CALIFORNIA i�� _ 6� t 95 Na:M i 6- 2z7 �eo�� 3 ` DE9CRIPTI 65x t o8. z8 � N�;.,°�w `°�s. o .--•- � S6TBACN LINB PROM C/� � � I LERT J i I RIGHT `Ot DESCRIPTION OF WORK I x II .. ��e.y,,,u I II e��,r,.,u F EE RECEIV ED �7`� FINANCE DEPT. ��TY OF COSTA MESA APPLICATION FOR PERMIT BUILDING For Office Use Only aece�rr No. .geAprtyy�i -LtJ ! ev ow r� veo owre �enueo - l=�-!�/�.... ,. COSTA MESA, CALIFORNIA ZONING NO. OF U8E OP N PLANB � BV�LDINO �� ■ ��w ��. a,.� BUILDING p NO. OF 7 BIZE � JzSF RO�MS I STORIES �� EXTHRIOH WAI.L TULCO gOOF OCK COVBRING COVERING USF.,,OF BUILD�yIG AND W,QRK TO BE PERFORMEpTTACHED JINGLE—rAMILY ttES�DENCE AND A ARAGE LAN — 1 HEpHBY AGKNOWIEDOE TXAT � MAVE RE�D TH18 APPLIWTION AND BTATE TH�T TH6 A60V8 IB COPAECT ANO AGREE TO CON- PLY WITH ALL CITY OqDIXANC88 HTATE LAWB RfiGULATINO BUILpiNa cOH9Tfi/UR�,ION. Ii SIGNATURE OF / 6' �/ . _ r �. _ _ _ ■ AUTHORIZED AGENT D�' THH AMOUM 6HOWN UNDER VALUATION I6 FOR TH8 PUIiPOBC OP EBTABLIBHING /� PERMIT FFE ONLY. VALUATION �jq PERMIT FEE S ..'j / — /7,. �s'3— /� S PLAN CHECK $ LX-.�