HomeMy WebLinkAbout155 MORRISTOWN LN - Building Permits 4` 9 CITY OF COSTA MESA �.
�!f! ` @@ BUILDING DIVISION
.44 DEVELOPMENT SERVICES DEPARTMENT P RMIT NUMBER
F t o rile
i PERMIT
B02-01154
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
BUILDING PERMIT
Job Address: 155 MORRISTOWN LN Status: ISSUED
Suite: Applied: 07/26/2002
Vicinity: 155-169 MORRISTOWN LANE Issued: 07/26/2002
Parcel Number: TPN98078 Zoning:
Applicant: BLANKS, JERRY ISSUED BY: (� _
Address: 17501 NORWOOD PARK PL v" "
Phone: (714)573-0155
TUSTIN,CA Zip: 92780
Owner: MONTICELLO COMMUNITY ASSOC.
Address 150 VALLEY FORGE
Phone:
COSTA MESA,CA Zip: 92626
Contractor: PREMIER ROOFING AND BUILDING CO INC
Address: 17501 NORWOOD PARK PL
Phone: (714)573-0155
TUSTIN,CA
Zip: 92780 License: 634404
Arch : Eng:
Address: Address:
Phone: Phone:
Zip: License: License:
SCOPE OF PERMIT
REROOF BLDG WITH ADDRESSES 155-169 MORRISTOWN LN FOR"MONTICELLO HOA":T/O FLAT ROOF ONLY, INSTALL
1 BASE,4 PLY AND ROCK WITH HOT ASPHALT.5500 SQ FT
FEE SUMMARY
Plan Check: $0.00 Calc Valuation: $17,000.00
Permit: $279.25 Claim Valuation: $17,000.00
SMIP Res: $1.70
SMIP Corn: $0.00
Other: $0.00
Inspection: $0.00
Total: $280.95
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
2446-46(WOO)
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 pf 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.'
workers'compatisation lasukace —f and
licy-qumber are: /4-6901/5--2
� l�p _p/
farrier ot /�/L`' 6-- 7 e mbar.
(Th' action need not be completed if the permit is valued at one hundred dollars($100)or less.) c J
❑ I certify that in the parlor•:nce 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 C.f fomla,and agree that hould become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
with these p'rof im / / /nn,�,,, i i'�
'• ature:T `� jNAC Cf —
W FAILURETO( od. •),WORKERS'CO ENCOS O COMPENEISUNLAWFUL AND SHALL IDED FcTOR IN FTE OR ES ANDiOESUP 1OtN Y'S HUNDRED.
THOUSAND OOLIARE(51000d' ••),IN ADDRION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR ODDS,INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereb at am licensed and pr visionsof Chapter 9 commencing with Section 7000)of Divisl a siness ad Profess' s Code,and my license is in full
for .Lic.# ,-i/ QT Class# "<3
o ctofs ' ature: es,,,-.. /f�,r ate: dy,-2 /Q-2---
J
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(commenting with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom end 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 properly 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. ❑Yes 0 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,California Administrative Code).
❑ 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 0 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 If an RMPP is presently required,has Section 25534 of the Califomia 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 apermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? 10 Yes LJ No
(Section 65850.2 of the California Government Cade 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 ❑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? ❑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 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 agre to comply witltall s e laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-descri d pro e,t,t sp ion purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
l
11 �t Signaturef gal Owner(s) 7A9/&p_____
And/Or Authorize liwnt te
ODE I., INSPECTION TYPE C PATE 1NTRIALS CODE( INSPECTION TYPE ) PALE INTRIAL$
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final Q yv208 Final Plumbing
S
200 Final Re-Roof r /- � 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
Applicant to fill In all spaces except those within heavy border lines and sign all appropriate declarations. - _ . _ -
CITY OF COSTA MESA _ PERMIT NO. TRACT NO. LO• T NO. BLDG.NO. i , - -
CONSTRUCTION PERMIT P /27 S�' ' •
Project Address ' _ _ a 0/ r A A TYPE OF CONSTRUCTION `t.NEW U ADD U ALTERATION U REPAIR • RCCR L/I [iof' " ni ' it
Applicant's Maili Address .t_ r tate. ❑ CONVERSION ❑ DEMOLISH ❑ OTHER -- A.P.#_ ' Zone .
T9,g DESCRIPTION OF WORK
Owner's Name rSoId ' a Phone/Y/446( I '
/ � .�Ff�/fP)/ S Main Building: Accessory Building: Z
Address "kw L 4 - "W/Mfg TYPE OF PERMIT ❑ GRADING 1((( FOUNDATION '
U STRUCTURAL T Fronk N
Arch/Eng. -_ - - - - License No. 0 TENANT 0 ELECTRICAL t LUMBING ❑ MECHANICAL B -
A Rear - N
Address - ''JJ yJ I,� 0-OTHER
tbContractor's NamejI/^r. &1 vselSke'ePhon PROJECT DESCRIPTION SQ. FT. OCCUPANCY C Right • - G
r11�� •
Address(mailing)rjehi 41/4.4 ^11^$I.. �(./�' � CONSTRUCTION TYPE VALUATIONS s Left E
J/ / ZONE ' - GRADING CU.YDS. ACRES Ping?Ref,# , ' Park.Fees $ Q
City License No. w LJ
A LICENSED CONTRACTOR DECLARATION Remarks: Parking Req./Provided I
I hereby affirm that I am licensed under provisions of Charter 9 (commencing - R
with section 7000) of Division 3 of the Business and Professions Code,and _ Use o• f Building: E
my license is in full}Or hi ' fect.
Ucen - Cl. _v 1� ens:. 0 PLUMBING FEES Planning Notes: M
Date '—"..•—• Signature ., er4 r _ •r . E
JRKERS'COMPENSATION DEC • RATION Be!Sink Showers T
T
.ereby affirm that I have a certificate of consent to d self-insure •r a certificate Backflow Preventer Service Sink S
of Workers' ompensa[ion Insure co, or a cert •tl copy t •r¢Of (Section
3800, Lab. �`• �/f , P� Backflow Irrigation Sewer Cap '� ELECTRICAL FEES
Policy No. LJ� IO7.2 Company /a _ --
/l� Certified copy is ereby furnished. /• J • Bathtubs Sewer Connection Automatic Washer Transformer 0 15-50 KW
(PQ,C r ifi o s fled with the city ••nf.i Iv.'• •
Date Applicant `• 4�!��141 Clarifiers Solar Collectors • Construction Pole Sub. 0 50+KW
EXE ION FROM WORKERS'COM• NSATION DECLARATION -
Dishwasher Solar Piping Cooking Unit Meter ❑up to 100 amps
(This section need not be completed if the permit is for one hundred ($100)or - •'
less). DrinkingFountains 1
I certify that in the performance of the work for which this permit I5 issued, I Solar Tank Dishwasher r, Meter Dover 100 amps •
shall not employ any person in any manner so as to become subject to the .
Workers' Compensation Laws of California. Floor Drains Swimming Pool w/Spa Dryers OGas DElectric Sub Panel
Date Signature -
NOTICE:If,,after making this declaration,you should become subject to the Floor Sinks Urinal Fan Motors 00-1 HP 01%-8 ,
Workers' Compensation provisions of the Labor Code, you must forthwith '
comply with such provisions or this permit shall be deemed revoked. Gas Service Outlets Water Closet F.A.U. Inc.Solar 09-15 HP 016-15+
CONSTRUCTION LENDING AGENCY - '
I hereby affirm that there is a construction lending agency for the performance Interceptors Water Heater Fixtures •Microwave
of the work for which this permit is Issued (Section 3097 Civ. C.)
Lender's /A- I e — - Kitchen Sink Water Service Device Boxes Pole Light
Lender's Address /('V'''j(�j'4,✓' (doze <n � ))M
OWNER BUILDER DECLA ATI N • Lavatories W,eTNsJ" �Jd Outlets Range
I hereby affirm that I am exempt from the Contractor's License Law for the P—Trap reason (Section 7031.5 Business and Professional Code: Any city or p Switches Sign
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 Roof Drains Garbage Disposal Standing Sections
••+ file a signed statement that he/she is licensed pursuant to the provisions of
Contractor's License Law(Chapter 9(commencing with Section 7000)of Generator ❑0-5 KW ❑5.15 KW Trash Compactor is'on 3 of the Business and Professions Code) or that he/she is exempt p
erefrom 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($500). Reinspection $25 Issue Fee $ 3
LJFee
I, as owner of the property or my employees with wages as their sole - MECHANICAL Reinspection Fee $25 Issue Fee $ 3
compensation, will do the work,and the structure is not intended or offered FEES
for sale (Section 7044, Business and Professional Code: The Contractor's PUBLIC SERVICES REQUIREMENTS:
License Law does not apply to an owner of a property who builds or improves . Boiler Hood or Type I ❑
thereon, and who does such work himself/herself or through his or her own Zoning Approved By Date
employees, provided that such Improvements are not Intended or offered for Canopy Type II ❑
Duct-Under Ground r
sale. If, however, the building or Improvement is sold within one year of com- Building Approved By Date /
prove the owner se have the burden of proving he/she did not build or Im- p
rove for the purpose of sale). Duct-Structural Refrigeration System Application Issued By i� • Date AG 6
O I,as owner of the property,am exclusively contracting with licensed con- ❑0.100,000 BTU ❑100,000 BTU
tractors to construct the project(Section 7044,Business and Professions Code: Duct-Ventilating SUMMARY OF FEES
The Contractor's License Law does not apply to an owner of property who BUILDING PERMIT •$ SMIP $
builds or Improves thereon,and who contracts for such projects with a con- Exhaust System 0 Multiple ❑ System Repair/Alteration •tractor(s) license pursuant to the Contractor's License Lawl. PLAN CHECK - $ PERMIT
❑ I am exempt under Section B.& P.C.for this reason Firepl/Fact.Blt. ICBG#• PLUMBING $ 5------_ ISSUANCE $
•
Date Owner - Heating System& Ducting _ PLAN CHECK 25% $ ENERGY P.C. $
I hereby certify-that I have read this application and state that the above 00.100,000 BTU 0100,000 BTL - ELECTRICAL $ GRADING $ '
Information is correct. I agree to comply with all city and county ordinances
and state laws relating to build' 9 construction, and hereby authorize repro-
PLANCHECK 50% $ MICROF
sentatives of t cit o u he above-mention rt
aye
Inspection Our es. °Cf.pr� MECHANICAL $ TOTAL FEE $
Signature Dat;
37
Ucense or 55#
�SReinspection Fee
-$25 - Issue Fee $ 3 PLAN CHECK 25% $
-
CMF 0865-46 rev.12/83 White-Building;Canary-Applicant;Pink-Accounting;Goldenrod-Assessor
-•CONSTRUCTION'AND PLANNING PO( SPA
r Date Inspector -Date. Inspector
, APPROVALS Permit# APPROVALS Permit#
T: Temporary Electrical Service or Pole _ 52. Pool & Equipment Location . • -
i 2. Soil Pipe-Undrgrnd. . _ . __ 53. Steel Reinforcement . r
3? Electrical Conduit Utility-Undrgrrid. 54. Forms -
4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding - ' •
•
5. Steel Reinforcement . - 56. Rough Plumbing & Pressure Test • "
6. Electrical UFER Grnd. - 1 . 57. APPROVAL TO COVER-GUNITE - - ,
7. Footings , 58. Electrical Conduit-Undrgrnd. - ,
8. Foundation59. Gas Pipe, 0 Undrgrnd., Test - `
' 9. Water Pipe-Undrgrnd: 60. Backwash Lines, P-Trap, 0 Undrgrnd. -
10. Structural Floor System t 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 Electric Wiring 67. Fencing & Access Approval --
17.; Rough Wiririg:Sign68. APPROVED FOR PLASTERING � .
18. Rough Electrical-T Bap Ceiling I - - 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 0 Oil
- 23. Gas Pipe-Rough & Test i 72. Underground Flush
•
: 24. Roof Framing 73. Undergrnd.Storage Tank 0 Gas 'Oil . '
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 (
29. Insulation 78. FIRE PREV. FINAL i
30. Drywall Nailing HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat 79. FINAL INSPECTION
32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED
33. Final Electric ' Notes: L EFr C42D- '11/47/et Leo
34. Final'Heating&'Air'Conditioning ' .
35. Final Gas Pipe-Test
36. Hood or Canopy, 1
37. Final Factory Fireplace
38. Final Plumbing 'QM 6( Lip -
39. Water Service-Final l
40. Gas Service-Final
41. Solar Domiestic-Final ! , ' '
42. Backflow Preventers ' -
43. Backflbwirrigation -
44. Landscape Irrigation System i.-
45. Sourid Attenuation ' • - - -
46. Handicap Regulations . - ' .
47. FINAL STRUCTURE & BUILDING:
48. Special Requirements Completed -
49. Electric Release to Edison i - -
50. Gas Release to Southern California Gas Co - •
51. CERTIFICATE OF OCCUPANCY ,
No. - Date' -
Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations.
CITY OF COSTA MESA CONSTRUCTION,PERMIT - PEWIT NO TRACT(� Q' TRACT NO. LOT NO. UNIT NO.' •
•
Project Address AS 014Trl rowh, GF/✓- s9 ✓ ! 9
TYPE OF CONSTRUCTION ❑ NEW U ADD ALTERATION U REPAIR
Applicant's Mailing dress ❑ CONVERSION ❑ DEMOLISH ❑ OTHER # Zone
Owner's Name //ye � �A�,'T Phone Tyab6� A.P.DESCRIPTION OF WORK/USE OF BLDG. S Main Building: Accessory Building:
Address '• ,pS25 rzsrnr c.u,t. C'✓• 2
Arch/Eng. License No. TYPE OF PERMIT U GRADING L„f FOUNDATION ❑ STRUCTURAL T Front Q
Address tar•
- 0 TENANT 0 ELECTRICAL Ij4"I PLUMBING ❑ MECHANICAL B Rear N
Contractor's Name n �IVl9C� Phone CPI-47,73' ❑ OTHER A
C Right - N
�e � � PROJECT DESCRIPTION SQ. FT. OCCUPANCY K g • G
Address(mailing)3®' r CONST RUCTION TYPE VALUATION$ $
07 N� Left
City License No. OI ZONE GRADING CU.YDS. ACRESE
LICENSED CONTRACTOR DECLARATION Ping. Ref.`//' Parking Req./Provided
I hereby affirm that I am licensed under provisions of Charter 9 (commencing Remarks: /s),',r/ ,per ''jA`' Planning Notes: M
with section 7000) of Division 3 •f the Business and Professions Code,a d "'�"u'}L Ca C•(q • T
my license is In full force .nd effe- . a
License Class p. , O - - S
Date / Sr Signature HPIVRilf at _ 4 PLUMBING FEES
WORKERS COM'ENSATION DECLAR• ION Bar Sink Showers , ELECTRICAL FEES
hereby affirm that I have a certificate of consent to s•If-Insure or a certificate
\ f Workers' Compensation Insurance, or a certified copy thereof (Section Backflow Preventer Service Sink - -
38o0, Lab. C.` J//// ��//77z /(�, /n-f--'�/_ Automatic Washer Transformer 0.15-50 KW
Policy No. j)C._5p(i/O�6-ompany J Backflow Irrigation Sewer Cap Construction Pole Sub. 0 50+ KW
\ r Certified copy is hereby furnished.
Certif tl/�p�I'6,"( with the cit r(tl��in ,�—/A sipP Ate Bathtubs Sewer Connection • Cooking Unit Meter ❑up to 100 amps
a e aj/ r�y Yi,1 Applicanty K/i`< UN.C�l
EKEMPTI N F OM WORKERS'COMPEN ATION DE LARATION Clarifiers Solar Collectors Dishwasher Meter Clover 100 amps
(This section need not be completed if the permit is for one hundred ($100) or
less). Dishwasher Solar Piping Dryers OGas DElectric 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 manner so as to become subject to the Drinking Fountains Solar Tank Fan Motors 00.1 HP 01-4-8
Workers' Compensation Laws of California. I -
Date Signature Floor Drains Swimming Pool w/Spa F.A.U. Inc.Solar 09-15 HP D16-15+
NOTICE:if,after making this declaration, you should become subject to the —
Workers' Compensation provisions of the Labor Code, 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 Boxes
I hereby affirm that there is a construction lending agency for the performance tJfl''6 Pole Light
of the work for which this permit is issued (Section 3097-!.Civ. C.) Interceptors f • 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 Live for the Lavatories Auto-Wash Garbage Disposal Standing Sections
following reason (Section 7031.5 Business and Professional Code: Any city or
county which requires a permit to construct,alter,improve,demolish or repair P—Trap Laundry Trays
any structure, prior to its issuance, also requires the applicant for such permit Generator 0.5 KW 05-15 KW Trash Compactor
to file a signed statement that he/she Is licensed pursuant to the provisions of Roof Drains
the Contractor's License Law(Chapter 9(commencing with Section`,7000)of
"'vision 3 of the Business and Professions Code) or that he/she Is exempt
erefrom and the basis for the alleged exemption. Any violation of Section
J31.5 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 Reinspection Fee I $15 Issue Fee $ 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 forIFiI,rhu1.l
sale. If, however, the building or improvement is sold within one year of com- Zoning Approved By Date
pletion, the owner will have the burden of proving he/she did not build or im- Building Approved Byprove too the r of the of ope). Date
D I, as owner of the property, Se exclusively contracting with stens con- Application Issued By (_..//sl�/� Date
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 SUMMARY QF FEES
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 aware thataust ystem on BUILDING PERMIT $ SMIP $
proof of then Worker's Compensation insurance should be provldetl to me.
PLAN CHECK $ TPERMIT
0 I am exempt under Section B.& P.C.for this reason t• PLUMBING S 1 O U ISSUANCE S
Date Owner aPLAN CHECK 25% $ ENERGY P.C. $ -I hereby certify that I have read this application and state that the above ■ s •ss0 : •s •as : ELECTRICAL $ GRADING $
information is correct. I agree to comply ith all city and county ordinances
and state laws rel. Ing 0 building co• tion, and hereby authorize repre- PLAN CHECK 50% $ MICROFILM $
= •r
•sentatives of •i- cit tenter •• e .•ove-mentioned pr.•erty for
Inspection p •• MECHANICAL $ TOTAL FEE $ Cl- Da
Signature / d a./ b a f 4 Dat i •
Dr%vars' License or • _ '' r Reinspection Fee $15 - Issue Fee $ 3 PLAN-CHECK 25% $
CMF 0865-46,rev. 10/84 White - Build' g; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor -- 1)�l+.7 ..� ._ -
.r 1. 1.ILt l_'_:
CONSTRUCTION AND'PLANNING POOL &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. 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, O 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 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 ❑Oil
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 76. Dry Standpipe
28. Lathing & Siding 77. FIXED SYSTEM FINAL
29. Insulation 78. FIRE PREY. FINAL
30. Drywall Nailing HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat 79. FINAL INSPECTION
32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED
33. Final Electric Notes:
34. Final Heating & Air Conditioning
I'
35. Final Gas Pipe-Test -
36. Hood or Canopy
37. Final Factory Fireplace
38. Final Plumbing be/t [11
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
47. FINAL STRUCTURE & BUILDING
48. Special Requirements Completed
49. Electric Release to Edison
50. Gas Release to Southern California Gas Co
t51. CERTIFICATE OF OCCUPANCY •
No._ Date
•
*ADURly+`SWIM: 155 MORRISTOWN-1N UMI _ . _. . .. — - , CITY _OF COSTA MESA. —.,BUILDING PERMIT I
OWNERS Wain KNOWN: CARR, PAULINE S TR - - - PERM NO: ,B 073439 .
AODREss 155 MORRISTOWN LN
COSTA MESA,CA 92626 PERMIT NO: B 073439 PLAN CHECK NO: N GOVT: N SUPP : N
APPL.IWUNG ADDRESS: CONSTRUCTION TYPE: VN PERMIT TYPE: STR PURPOSE: OTH
ARCHITECT OR ENGINEER: UC.NO.: JOB DESCRIPTION : T/OFF, SHEATH & REROOF W/ COMP SHINGLES( SQ FT: 2, 999
ARCH.OR ENG.'S ADDRESS: UMI:
CLAIM VALUE: 2, 999 .00 CALC—VALUE: 2, 999 .00 GROUP OCC: R-3 /
CONTRACTORS NAME STOUT ROOFING INC ( 310)923-6775
CDNTRACTORSMMUNO , P 0 BOX 4309 COMMENTS: SMOKE DETECTORS REQUIRED PER 91 UBC
ADDRESS: DOWNEY CA LICNO.: 402536 *+rx**+ESE************x**x**** it**************+t********x****x*RE** ***RE******x*N**+r
90241 mon: ZONING REQUIREMENTS
LICENSED CONTRACTORS DECLARATION:I hereby affirm under penalty of pedury that I am licensed under provisions of Chapter 9 SETBACKS
(commencing with Section 7000)of()Olson 3 d the Business and Profes' ode and my license is in full force effect.
CITY UC.NO.: 059377 LIC.CLASS: 39 LIC. .: 4 25 6 E 10/ 5 MAIN BUILDING ACCESSORY BUILDING
7--;!--9- Contractor l/ FYtNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN
Date: / EFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN
OWNER BUILDER DECLARATION:I hereby affirm under penalty of perjury that I are exempt from the Contractors Limnsw for the
following reason(Section 7031.5 Business and Professions Code:Any city o county which requires a permit to construct er,improve, PARKING REQ: _ P ROV: PARCEL: 41916509 Z NE: REF NO:
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 Dveion 3 of the PLANNING NOT E S>' =..
Business and Professions Code]or that he or she I.exempt therefrom and the basis for the alleged exemption.Any violation of Section >
7031.5 by any applicant for apermit subjects theapplicant to a civil penalty of not more than five hundreddoffan 155001). *******************************************************************************
❑ I.as owner of the propetly or my employees wth wages as thee sole compensation,will do the work,and the structure e not intended D E V E 'L O P M E N T SERVICES R E Q U I R E M E N 'Tc S
or offered for Bale(Section 7044.Business and Professions Code:The Contractors License Law does not appy to an Owner of property
who bolds or improves thereon,and who does such work himself CO herself or through he or her own employees.provided that such -
improvements are not intended cc offered for sae.lf,however,the building or improvement a sold within one year of completion,the ZONING APPROVED' B YDATE:
ownerbuilder will have the burden of proving he or she did not build or improve for the purpose of sale).
❑ I,as owner of the property.am excmwely contracting with licensed contractors to construct the project(Section 7044,Business end
Professions cos.:The Contractors Irene.LASS ems net appy to an ower a property was wilds or impresses thereon and wfnBUILDING APPROVED BY : DATE:
contracts for such projects with a contractor(s)licensed pursuant to the Contractors license Law).
❑ I am exempt under Section: B.BP.C..for this reaam: APPLICATION ISSUED BY: DATE: /� ID
***************'****************** * * **************************** *
Date: OwnerLEGALIZATION:NF E E UMMARY STRUCTURAL SEGMENT:Y
I do hereby ceniy that I am aware of and understand the requirements of California Health and Safety Code Sections 25505,25533,and
25534.and that I or any hnure building occupant will/wit not(cafe«n)need to comply with said slate codes and the requirements b
a permit for construction or modification from theAk OuaktyManagement District.Residential construction application are exempt from these BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING
provisions. PERMIT 54 . 00 , . 50
Date: Applicant: SMIP/NON—RES
PLAN
WORKER'S COMPENSATION DECLARATION:I hereby affirm under penalty of perjury one of the following decimations: ISSUE FEE
❑ I and veil maintain a certificate of consent to self.insure foe waken.'compensation,es provided fa by Section 3700othe Labor BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE
e,for me performance at the work for which this permit is issued. TOTALS----> 54 . 50 0 . 00 0 . 00 54 . 50 54 . 50 . 00
I have and veil 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 carder and policy number are:
Carder: STATE EXPIRES REVENUE DIVISION TOTALS--> COLLECTED: 54 . 50 OVER/SHORT: . 00
Policy Number: 044941T00046A7 10/19/95 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK
(This section need not be completed it the canna is for one hundred dollars(5103)or less.) 54 . 00 . 50
o I penis that in the performance of the work for which this permit is i rr'h: I shall not employ any person in I anner so as lo
become subject to the workers'compensation Wm) California, . e that ) .11001d become sit,/ to the ).• re' * *****************************************************************************
conpensatio p snit°of�°3700c�of the Code,I shall '. : ne ^py those provisions
Dale: "'.1-•-•-/2' Applicant: �. /�1// �P_....I*J. / •�C/ I N D I V 2 D U A L F E E BREAKDOWN
Warning:Fallum to secure workers compensation coverage li unlawful,end shall subject an employer to criminal Wes and TYPE QTY DESCRIPTIO N UNIT COST TOTAL COST
civil fines up to one hundred thousand dollars($100,000),In addition to the cost of compensation,damages as melded for/n
Section 3705 of the Labor cow,Interest and anormeysleea. SFR 2999 REROOF BY VALUE RESIDENTIAL NOZONE 1 .00 2, 999 .00
CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty of perjury that there is a construction lending agency for the END OF FEES
performance of the work for which this permit is issued(Section 3097,Civ.C).
LENDER'S NAME:
LENDER'S ADDRESS:
I certify that I have read this application and state that the above information ls correct.I agree to campy with all city and county ordinances
and state laws relating to building construction and hereby authorize representatives of the city to enter upon the above-mentioned property
for inspection purpe 01 00187140-001.87141 TOT .'}4,50
Print erne / I//
r
DARL NE BURF�, % , vv—2,�9� GATE: 07/28/95 T1409:1b
,1 •r
Dale: •
Signature Owner/Agent/Appkcent/C°ntract«
(5151ae.WP) Whits-Building&Safely:Green-Ale;Canary-Appicant:Pink-Revenue;Goldenrod-Assessor
rCONSTRUCTION AND PLANNING POC. ` SPA
APPROVALS Permit Date Inspector APPROVALS Permit Date Inspector
li
1. Temporary Electrical Service or Pole 52. Pool & Equipment Location •
2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement •
,, i.,
<3:,Electrical Conduit UQlity-Und'rgrnd. 54. Forms
Z
• 1.29,z lectrical Conduit-U4drgrnd. 55. Electrical Bonding :
r .
"_c6 Steel Reinforcement 56. Rough Plumbing & Pressure Test �,
L-6:�Electrical UFERG?nd. 57. APPROVAL TO COVER-GUNITE •
•
�-•s-7: Footings 58. Electrical CondriiEUndrgrnd. r
8>Foundationy4 0 a. 59. Gas Pipe, 0 Uridr2�tnd., Test t'
't,4.=Water Pipe-UndrQrad. 4 - 60. Backwash Lines,e.Trap, GrUndrgrnd..
▪ 10. Structural Floor System 61, APPROVAL TO BEC
c aK
11. Property Sewer Line.& Housonnection62. Backwash & Receptor-Final . '
12. $ewer Cap 63: Heater& Vent-Final - •
T
13. Roof Drains 64. Plumbing System - Final '
14. Rough Plumbing- ch • 65. Electrical-Final
15. Rough Electrica Conduit c 66. Solar System-FTpal,
16. Rough Electric irir 67. Fencing & Acc&Ss-Approval'
W
17, Rough Wiring SrgnJ 68. APPROVED FQJ* LASTERING
18. Rough Electrical'T Bar Ceiling' 69. POOL/SPA SYSTEMS FII'jAL
19, Rough Heating & Air Conditioningg F�p E t EPT iEQUIREMENT >
20. aur F tor, Fi #ace ""w' �C' * '• 0•' r' G tri k �" '`
;q.1 I S,. xr + r. cr.,; ,,APPELoV� i_ r,„ it# - e.-..
Pi
21. Suers, intstruaurr^.* '• -• x '- Ci r'* 70.FDnder�r�Gr l l- dro x
22. Duch Vei�til in '4' ns r. •�' Ewing as
, max.• 6 .- r-. r 71. Product Ewing floes L3 Oil . .
23. hes Rupe-Rough & Test .•,S t m c Q 0* 72. UndergroZ hd FFusi 4 ' ti
24. r'oof`Frahling- " ::_ ..:7 t ' 7 t. S 2-1
.. 7k, Undergrnd.Storage Jlenkx❑Gast❑Oil
25. Roo6Sheathing 7. e --1,-. �6;k/if 7$'i +jverhead HydrR_ * . .
26- -BaT.Ceiling (Strukttiral) '& A'hinocoat s C. r, 7.3 b.' 7cc.&)1.v Chetpical He, -r •--11-
qr,:-•
;7---7---ad '-•17. * r*c mr.: _.
27. Frame and.Flashirm D�7 * !- > sax 76. Dry Starji,^npe,:'W n; G
28. Lathing${;Sithg ?* • i 7:::r O T. -T. -, - K 77j FIXEDTErify-INAt,-: Cl r
Y29. Insulation" •�• o.;*
c . _* -. I I 7g FIRE PR EV. F,I,NTAL k
r--30. Drywall63ai6rSjf y * I x S 3ALT},DEPt RE&JIF1 MENT
w _ .._�
c'31. Plaster Brown-Coab{ s r : I �*t 79,� FINAL CAISPECTION x - - C
TT 32. ElectricaFFPosfe,r IVAtIr`FEeal i * CO I x T 80� FOOD CERTiF+pATE IrSWEcL. crz
r! K ! (••K . c' R ,d t l ..Z
r 33. RnafrElectric> * c' w '- r Notes: "T ^ j �m
t^z. '^' -. . - - - - e ^• . ;x -. c ,1 r. "S
1%34. Fina Riealiin AT,C< nditioriirig S r; * ,� I " - S r x .r S .i7
EH S g AT,
x r ' C+7 '% .* N •-, :H C• *
35. Anal Gasseipe:rr-tSesti*. O, * .-. tr p zc, 7 y- FiT
M: i T' .• •,r * ) fit m . -•'I a rn •.y
?
36. Hoodtor Canopy x U ' C-, .4- `e F_ r :,d 'xn'
_ r. .7 f :^. a.IT .-, f ^ tT .7.4..-.7"... Y Y .-ET:
17 37. lndrFdC/Oty Firapac'er c ' F•F' ‘.1-- * t. { a
I
T
-
_,38. Fina •Plukibin C
---'.39. WaterZService.tinal }. r J x IR 4 :, ` � c'
*
rr
40. Gas Service-Fr▪al I p, c""' S * t' 1* 9.a. roc"
4 - :r^ r r IS 7.1. * -a:
141. Solar Do st -Finals - Z.*: tic ,ti ` T
0 *
•.
42. Backflow(Qreventer * i-i x y . I- 11:11: >E_ ' ` C' �'
II r1 *y� ..-y:-: * .-• x r: 71 O'.; * E-,
I., G.SS * # ., t-.0
43. Backflow Irriggtion x y t cc x 7; i ac'. •
44. Landsca lrrvgatiorr5ystem�ct•ty cc * m c' ei Glc c N to O I CO 0
•, x
Hi•X.t- r :K r t- H h r L . H. H L �.. h�..
45. Sound Attenuation* .- . .. t n1 mt F- c , < • t-G x
C1 -- - r -' .. .. ..* ^, : ,. ..� *
46. Handicap Regulations O .t .s C; G •5 •;:i0 S r
- yr �� .. v S . It t, LT:LO (U 3:
47. BiN i.STRITUR & BUILDING p G '' ::1..�5 ,_
48. INAL PLANNING, t a: I ;. '2 S
49. Elecfiic Releafe to Etlison ! l I .` '.r ' "E *
w I •C' K y
50. Gas Release to Southern Califor5'c' Co a i, ;, r. L. �O x( G • 0?1 x G..1C'
51. CERTIFICATE OF OCCUPANCY * a • ' " .
No. Date
OWNER SAN V1S''A Building Co. - DATE 7-21-67
JOB ADDRESS 155 Morristown Lane BUILDING PERMIT NO. 27297
GENERAL CONTRACTOR San Vista Bldg. Co. DESCRIPTION OF WORK Res.w/att.gar. _
AP No.930-03-244 LOT 244 TRACT 5160 FIRE ZONE VALUE $ 17,640.00
INSPECTIONS I Signature Date GROUP I & J TYPE V ZONE 11-3
Soil SFr -0' PERMITS ISSUED
Gas Ani. .e s-c. SUBCONTRACTOR I Date I Number I Signature
WaterLlp/I?-/S7 -2-7-4 7 ' -fir 'luo bing g ,
Itou;h Plumbing Yaw . -2-9-Cr•— /l li�: i�i�=�
Prop. Swr. Line 0 House Con.I /14-74-J-,-67-4-7 1
Sprinkling System
Miscellaneous
Rough Heating and Air Conditioning //271-S e-2--q-6.) ==
Temporary Service or Pole
Underground 0 Power D
Rough Wiring Wir -. -C Heating and Venty
Trenches Forms 0 Steel Reinf. ❑ f- fir
( 7, tzi_AM I,N • K-/1-67 ."723
Floor System IW„a `
Bond Beam 0 Steel Reinforce 0
Sheathing $ ' Q. X9/'2
Frame and Flashin i ,7yje cilg, 7
Lathing- In Out[� Cil
d,7
Brown Coat /' dt-% 7� I
Structural, Final a n
Heating, Vent., Refrig. and A.C., Final � -re7 Ke Elec 'c tii N-e7 1, �
Plumbing, Final and Gas Test SLl/ P'0'21-[ Y 1
Electric, Final V(/Cbb /C' f`r
i Buil(ling, Final I,4-. in' ii s'i
27297 JUL 25-67th;PAID *I`*..35.5C
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O. BOX 1200 COSTA MESA, CALIFORNIA P2620
For Applicant to Fill In Completely APPLICATION FOR PERMIT
TYPE OR PRINT BUILDING
1 SS 1 1 For Wilco Use Only
AO .
ADDRESS RECEIPT HO. P RMIT
W
YP
7eNT
O
f7COSTAMESA. CALIFORNIARI 77 DATE Jp
ISSUED
OWNER VQ,I.I , ,4AL/1LfQ } U .1" 7- VD7 `-7 f
4
7
BUILDING
MAIL ADDRIgY
ADDRESS d V�atepvcal SN.
1
CITY OGISNO '-I (•� ZONE TYPE I !GROUP \'yJ
APPROVED / /rye. 7/7--
ARCHITECT
DATE
OR ENGINEER vf2nd LYL( TQI / Y .
ZONING
ADDRESS cas-S//t_2 312eklOA(Q n&4Il
{20N PLANS UEIOFNIW
IR-3 Puw 2 I EuaDlxG Sing Res
CONTRACTOR 0 caLA .„
�/(
ADDREBe / .Q� ,.l{y� DESCRIPTION tfwv 1 et.n e -ri
(an
(a C? w✓ A.P.NO. 930-03-244
CITY
NOTE: NO EAVE OVERHANG SHALL BE LESS THAN
STATE TEL.. SO'TO SIDE&REAR P.L.
LIG.NO. NQ.
EAVES
SIZE ^ INO.OI SLDGI. ALLOWED (U.B.C.REQUIREMENT)
OF LOT h.O X_ 70 NOW ON LOT
YARDS APPROVED YARDS APPROVED
USE OF ���� MAIN BUILDING ACCESSORY BUILDING
EXISTING BLDG. ..
(FROM C/L STREET)
SETBACK LIRrFROM l FRONT 0 rT. PT.
CENTER OP STREET "-REAR YARD
SIDE YARD LEFTI RIGHT R.SIDR 0 Pi. PT.
DESCRIPTION OF WORK L.SIDE 0 PT. FT.
NEW I '�I'MOVING
DEMOLISH ALTERATION I I ADDITION
AIN BLDOB. . ACC
ET.
SS.BLDOB.
REPAIR JI'll1
BUILDING' �/c7 NO.OR VAR.# DATE
SIZE �J F `Q ROOMS �/-' STORIES •� C.V.P.OF / APPROVED
ROOF
CO Hp/RIOR .Pf}I COVERING /` !APPROVED /'c-Y•,+II DATE 7-7-67
WORK
USE
\ 1 et lq nt.f.(4.Qc/01 ./,(,(,(e1R/`ool . VV N
l ;rrrr,,,,
w� -V�� ag-SQ.FT /74.0P/ 2
I HERESY ACKNOWLEDGE THAT.I HAVE RIAD THIS APPLICATION THE AMOUNT SHO DER VALUATION IS FOR THE 2
AND STATIC THAT THE ABOVE,IS CORRECT AND AGREE TO COM. PURPOSE OP EGTA HLISHING A PERMIT FEE ONLY.
PLY WITH ALL CI DINANCEI AND STATE LAWS REGULATING VALUATION
SWLDINO CONSTR 1
SIGNATURE OF - T _ PERMIT FEE S
PERMITTED T./ LA-Lit" - /�//,
a/ "/ v PLAN CHECK S o.�/T ct w
AUTHORIZED AO 5 �� J 21
�.. - •;_ I +._„� ......_.'{.. TOTAL PEE .7