HomeMy WebLinkAbout1622 MYRTLEWOOD ST - Building Permits CITY OF COSTA MESAo
BUILDING DIVISION
Fµall d 77 FAIR DRIVE,COSTA MESA, CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us
4. ! FOR INSPECTIONS CALL: (714)754-5626
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PERMIT NUMBER: BX10-00086
PERMIT TYPE B_MISC STATUS: ISSUED
APN: 13919332 DATE ISSUED: 01/25/2011
Zoning: R1, ISSUED BY:
JOB ADDRESS: 1622 MYRTLEWOOD ST CM Suite/Unit:
Vicinity: ROOF TOP Primary Occ: Const Type :??
SQ. FT: 0 Valuation: $25,000.00
SCOPE OF WORK:
INSTALLATION OF A 5 KW ROOF MOUNTED PHOTOVOLTAIC SYSTEM FOR A SFD WITH AC/DC DISCONNECT, 1 INVERTER,
MISC EL, MISC CONDUIT.
OWNER: YOUNG SUSAN G Address:: 1622 MYRTLEWOOD ST Unit
City/State: COSTA MESA, CA Zip Code: 92626
Phone: 714-434-3844
APPLICANT: WAMPLER, DAVID Address: Unit:
City/State: Zip Code:
Phone: 714-434-3844
CONTRACTOR: License No.
Address: Unit:
City/State:
Zip Code: ' Phone Cell:
ARCHITECT: License No.
Phone
ENGINEER: License No.
Phone
FEE SUMMARY
Building Plan Check: $254.31
Building Permit: $391.25
Electrical Permit: $62.10
SMIP Residential $2.50
SMIP Commercial $0.00
Bldg Std Admin Fund $1.00
TOTAL FEES $741.66
HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/18/2010 -PER CMMC Sec. 13-279
Monday thru Friday-7:00 am thru 7:00 pm. Saturdays-9:00 am thru 6:00 pm. Prohibited all hours-Sundays and the following Federal Holidays:
New Years Day, Memorial Day, Independence Day, Labor Day,Thanksgiving Day and Christmas Day
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: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
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.
CODE S. INSPECTION TYPE DATE INTITIALS CODES INSPECTION TYPE DATE INTI➢ALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical �J ,,�/�
200126
Spa Final
8 Final
ing
6 Final Re-Roof 2110 Final Electrical X H.Pyr�M at
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 X /pp
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WORKERS'COMPENSATION DECLARATION: Owner ID verified by drive. _„cense. Yes 0 No ,
❑ I have and will maintain a certificate of consent to self-Insure for workers' Verification of Ownership by(type of'document,i.e.-property to bill or deed):
compensation, as provided for by section 3700 of 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 DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. My workers' compensation Insurance carrier and policy 0 I hereby certify that no excavation five(5)or more feet in depth into which a
number are: person is required to descend,will be made in connection with work authorized
Carrier by this permit,and that no building structure,scaffolding,falsework,or demolition
(This section need not be completed d the permit is valued at one hundred dollars(5100)or less) 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).
Policy Number:
-8....,7-r
•uilder, I will not employ anyone to do work which would
❑' I certify that in the performance of the work for which this permit is requi -it from the Division of Industrial Safety,as noted above,unless
issued,I shall not employ any person in any manner so as to become subject such as a permit to do such work from the divisioto the workers' compensation laws of California, and agree that if I should 1 71 (/
become subject to the workers' compensation provisions of Section 3700 of / Applicant's Signature / Date
the Labor Code,I shall forthwith comply with these provisions. '
Division of Industrial Safety Permit Number:
Applicant's Signature Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? 0 Yes 0 No
($100.000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS (Section 25505 of the California Health and Safety Code requires, with some
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND exceptions, that a Business Plan be filed with the Costa Mesa Fire
ATTORNEY'S FEES. 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
LICENSED CONTRACTORS DECLARATION: 500 pounds,or a volume of 55 gallons,or 200 cubic feet of compressed gas
I hereby affirm that I am licensed under provisions of Chapter 9(commencing at standard temperature and pressure).
with Section 7000) of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file
my license is in full force and effect. a registration form for acutely hazardous materials? 0 Yes 0 No
Lic.# Class# (Section 25533 of the Califomia 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
Contractor's Signature Date 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
CONSTRUCTION LENDING AGENCY: temperature and pressure).
❑ I hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to
performance of the work for which this permit is issued.(Sec.3097,Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely
Lender's Name; hazardous materials)? 0 Yes 0 No
(Section 25534 of the California Health and Safety Code provides that the
Lender's Address: Costa Mesa Fire Department may require the preparation, certification and
firing with the Fire Department of an RMPP by businesses which are required
to register acutely hazardous materials with the Fire Department.
Signature Dale
4. If an RMPP is presently required, has Section 25534 of the California
OWNER-BUILDER DECLARATIONS: Health and Safety Code been fully complied with? 0 Yes 0 No
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for
CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, the work which is the subject of this application a permit for such construction
Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from
construct, alter, improve, demolish, or repair any structure, prior to its any other air pollution control district or agency? 0 Yes 0 No
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 (Section65850.2fu of the on Califomia Gons for
Code requires thnt the requested
License
es Law osr 9 Code)(commencing th Section is 0)of Division 3 of the
information be furnished on applications non-residential building permits).
Business and Professions Code) or that he or she is exempt therefrom and 6. Will any pan of the facility to be constructed under this permit be within
the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? 0 Yes 0 No
applicant for a hermit subjects the applicant to a civil penalty of not more than (If"yes", the facility must meet the requirement of Sections 25534 and 42303
five hundred dollars($500).): of the California Health and Safety Code).
❑ I, as owner of the property, or my employees with wages as their sole 7. If a permit from the South Coast Air Quality Management District or other
compensation, WILL DO THE WORK, and the structure is not intended or air pollution control district or agency is required for the work which is the
offered for sale(Sec.7044, Business and Professions Code:The Contractors subject of this application, have all of the disclosures prescribed by California
License Law does not apply to an owner of property who builds or improves Health and Safety Code Section 42303 been made? 0 Yes 0 No
thereon,and who does such work himself or herself or through his or her own
8. (If"yes",attach certificate of compliance from the appropriate air pollution
employees, provided that such improvements are not intended or offered for
sale. If, however, the building or improvement is sold within one year of control officer).
completion, the owner-builder will have the burden of proving that he or she CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the
did not build or improve for purpose of sale.). information given above is correct. I agree to comply with all state laws and
city ordinances regarding Hazardous Materials and Emissions.
❑ 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 Signature Date
property who builds or improves thereon,and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
a contracta(s),,liicce e pursuant to the Contractors License Laws.). certify under p:n-fly of perjury that I have read this application and state that
the informat'• e•r<en is correct. I agree to comply with all state laws and city
• ❑ I am ex6efn under sec. i
ordinance :I.ling to building construction, and authorize representatives of
Business,-/ •lfessions Code for this reason: the City/.jr..la Mesa to enter upon the above-described property for
inspect'. p. ••see. I agree not to occupy or allow occu••ncy of . y building
author 9.' rhis per. it until final inspection. /
Z � l/ �/1 ZS / 7
Signature of Legal Owner(s) 0-e
/ 7/ Signature Dal '
3O .-P/07) ,
And/Or Aulbonzed Applicant Dale
Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations.
-
CITY OF COSTA MESA CONSTRUCTION PERMIT PERMIT NO. TRACT NO. LOT NO. UNIT NO.
Project Address /On- , (TLR1./Co/n S� 'BZ S 33 :9n17 IL
Applicant's Mailing
a./A� ddress TYPE OF CONSTRUCTION ElNEW LI ADD L I ALTERATION L I REPAIR i
Owner's Name •• 1JTTdliln-. r5/0-2-75,w'vff Phoner5/0-2-75, ❑ CONVERSION LI DEMOLISH �' OTHER 4-4-404a0c A.P.# Zone
DESCRIPTION OF WORK/USE OF BLDG. TEAR OF.- dam/) A5coFc
Address /612 /7 Ifl7C!'A.r+'°D Co>n7 M/•S.g Aal ?-771 CoAHS'.n
/ .5.r..rt6L/rf S Main Building: Accessory Building:
Arch/Eng. License No. TYPE OF PERMIT L1 GRADING LI FOUNDATION LJ STRUCTURAL T Front 0
Address ❑ TENANT III ELECTRICAL 171PLUMBING IIIMECHANICAL Rear N
M
Aontractor's Name SAYi 44/4- /toOF.� Yf's
.tw'. Phone c -T707 IQ OTHER AFROOF
PROJECT DESCRIPTION SQ. FT. 4/700 OCCUPANCY dent
C Right N
Address(mailing) ftQ• On*, /p<<' -savng4444 907n2>evsr A Z.
CONSTRUCTION TYPE VALUATION$ '?'ei .140/1 S Left G
60 City License No. 02S-3AB ZONE GRADING CU.YDS. ACRES-
•
R
k•LICENSED CONTRACTOR DECLARATION Ping. Ref.# Parking Req./Provided E
I hereby affirm that I am licensed under provisions of Charter 9 (commencing Remarks: Planning Notes: 0
with section 7000) of Division 3 of the Business and Professions Code, and M
my license is in full for e and effect. T
License Clas C License'N ' S
Date C- -S57 Signature . .ON.-* /Lfi7 . PLUMBING FEES 7
•WORKERS' COMPENSATION DECLARA4'ION Bar Sink Showers
I hereby affirm that I have a certificate of consent to self-insure or a certificate ELECTRICAL FEES/
of Workers' Compensation Insurance, or a certifi•• c•• there. (Section
3800, Lab. C.)
it s / Backflow Preventer Service Sink / Automatic Washer Transformer 0 15.50 KW
• Policy No. 2s,rs-- PS-L"/5a Comp. -4:1,/ / kflow Irrigation Sewer Cap0 SO+ KW
�l Certified copy Is hereby furnished. , / nstruction POI¢Sub.
!SI
Certified co is filed with the cit B v •Ing DI JiJj ' Batht Sewer Connection Coo • Unit Meter Opp to 100 amps /
Date°-yam Applicant/A - - s / ,
EXEMPTION FROM WORKERS'C•MPENSA ON DECLARATION Clarifiers Solar Collectors Dishwash Meter Dover 100 am
(Thissection need not be completed if the pe it Is for one hundred ($100) or --less). Dishwasher Solar Piping Dryers ❑Gas Electric Sub Panel
I certify that in the performance of the w r for whi h this per is issued,I
shall not employ any person in any ma r so ass//(recome bject to the Drinking Fountains Solar Tank Fan Motors❑ HP ❑1%-8
Date ''Cor7Pensy_ Laws of Califon /"! —_
Date JJ ..''33 Signatures •(-l�+'+� G Floor Drains Swimmi . Pool w/Spa F.A.U.
NOTICE:If,after making this declar ion,you should become subject to the Inc$ r 09-15 HP 016-15+
Workers' Compensation provisions f the Labor Code, you must forthwith Floor Sinks Uri•. Fixtures
comply with such provisions or this permit shall be deemed revoked. _ - crowave
CONSTRUCTION LENDING AGENCY Gas Service Outlets -r Closet Device Boxes
I hereby affirm that there is a construction lending agency for the performance Pole Light
of the work for which this permit is issued (Section 3097 Civ. C.) Interceptors Water .ter Outlets
Lender's Name -
Lender's Address - - _ Kitchen Sink Water Service
OWNER BUILDER DECLARATION Switches Sign
I hereby affirm that I am exempt from the Contractor's License Law for the Lavatories Auto-Wash
following reason (Section 7031.5 Business and Professional Code: Any city or - Garbage Disposal Standing Secti
county which requires a permit to construct,alter,Improve,demolish or repair P—Trap ,
any structure, prior'toAts issuance, also requires the applicant for such permit Laundry Trays Generator ❑0- W❑5 15 KW Trash Compactor
to file a signed statement that he/she is licensed pursuant to the provisions of , Roof Drai •
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
7031.5 by any applicant for a permit subjects the applicant to a civil -
penalty of not more than five hundred dollars($500).
0 I, as owner of the property or my employees with wages as their sole Reinspection Fee I $15 Issue Fee N:\3\5
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 forBo'ler 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
pletion, the owner will have the burden of proving he/she did not build or Im- Duct- n Ground Building Approved By
prove for the purpose of sale). - Date
❑'I, as owner of the property, am exclusively contracting with licensed con- Duct-Structural Refrigeration System Application Issued By 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 whoVentilating0o-100,000 B 100,000 BTU- SUMMARY OF 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 thatBUILDING PERMIT $ 3 P • 5o SMTP $ Q•S0
proof of their Worker's Compensation insurance should be provided to me. Exhaust System 0 Multiple 0 ste ¢pair/A lterati0n
PLAN CHECK $ PERMIT
0 I am exempt under Section B.8. P.C.for this reason Firepl/Fact.Blt. ICBG# ire Da rs PLUMBING $ ISSUANCE $
Date Owner Heating System&Ducting Registers PLAN CHECK 25% $ ENERGY P.C. $
I hereby certify that I have read this application and state that the above 00.100,000 BTU 010 OBTL GRADING $
information is correct. I agree to comply w h all city and county ordinances ELECTRICAL $
and state laws rating to building constr ion,and hereby authorize repro- -
PLAN CHECK 50% $ MICROFILM $
sentatives of 5 city to en r upon above-mentioned property for
inspection s s. �� J�/� t MECHANICAL $ TOTAL FEE $ 3,•B
Signature =� ��h! ' ate$L/�h , .
Drivers' License or 5S# Rei ection Fee $15 Issue Fee $ 3 PLAN CHECK 25% $
CMF 0865-46,rev.10/84 White - Building; Canary -Applicant; Pink -Accounting; Goldenrod -Assessor
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, 0 Undrgrnd.
10. Structural Floor System 61. APPROVAL TO DECK
11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final
12. Sewer Cap 63. Heater & Vent-Final
13. Roof Drains 64. Plumbing System - Final
14. Rough Plumbing 65. Electrical-Final
15. Rough Electrical-Conduit 66. Solar System-Final
16. Rough 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 0 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 PREV. 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
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
47. FINAL STRUCTURE& BUILDING1¢y
48. Special Requirements Completed v I
49. Electric Release to Edison
50. Gas Release to Southern California Gas Co
51. CERTIFICATE OF OCCUPANCY
No. Date
OWNER TIIIME PCRFS Inir. DATE 6-3-59
JOB ADDRESS 1622 Mvrtlewood Street BUILDING PERMIT NO. .9b92
GENERAL CONTRACTOR Dike and Colegrove • VALUE S 13,715.00
AP. No. LOT 122 TRACT 2822 FIRE ZONE DESCRIPTION OF WORK lies, at gar,
INSPECTIONS 6-/9-39 DATE I GROUP I & J TYPE V ZONE R1
Underground Soil/jyfS U.G. Waters g, -2.7.-gPERMITS ISSUED
Underground Gas
SUBCONTRACTOR DATE NUMBER
Overhead Water and Gas ,/
Rough Heating ?S--S-,• ilei e . %/J i :::-7---. 4__ 2:, /5 -ki .,G e://l%
Rough Plumbing NNS r".6 S /r
2 -, ,L,.-C,.' .i,,, /-J- -; `= ir.v4-51
Miscellaneous _ _
Prop. Swr. hifig_ f o
Housve n. St. Swr. /d - t.,-7:767-7.—en- - -' 7(3075 L (&- 4'O - P'
Sprinkling System a
' Heating, Final Ai5 ,w 7�j L
Plumbing Fixtures �_
Final Gas Test /4-94,-S-5'
Construction Pole
Underground Power
Rough W' ' g 72,4 ,2a /inriZT!/e- /—/S-5�%70 O t/Trenche %d.Porms le- Steele .6/s7/-5",
Floor Sys m
Steel Reinforce Chimney Re-Rod
Bond Beam
Sheathing :, 9M �'- frf ,hy
Frame and Flashing if el 8,-/H-5"4
Lathing, In , Out X"Pe 8-25%-5"/
Plaster, brown coat t iild 4 -1K--6`t
Plumbing Fixtures, Final1, ti-•-^w0-/
l �'
Electric Fixtures, Final Z,•,777 ' I
Building, Final Jo -).- _
OCCUPANCY r ,TM�
Form 210-3M-4-59 74 y2
• 949rt U J.
Q. JC:: 3 1959
COSTA MESA BUILDING-SAFETY DEPARTMENT „ICE DEPT.
P.O.BOX 317 COSTA MESA. CALIFORNIA III fill .
CI' I•.^Cv. +i Ch.
FOR APPLICANT TO TILL /N COMPLETELY APPLICATION FOR PERMIT
TYPE OR PRINT BUILDING
BUILDING
ADDRESS 1622 Myrt.lewnnd St.
COSTA MESA. CALIFORNIA FOR OFFICE USE ONLY
•OWNER Adams Acres, Inc. I RECEIPT NO. CjflMIT_NO. /
MAIL 419 E. 17th St. RECEIVED BY DATE RECEIVED
, /DATEE,IISSULED—�'
ADDRESS 6�J - 6 -,-)-V / I (e-—) —`., /
CITY
Costa Mesa TNG. L181159 BUILDNG
ADDRESS
ARCHITECT Carlson & LIC. COSTA MESA. CALIFORNIA
OR ENGINEER NO. n
Middlebrook FIRE �� I/
ADDRESS
}��gq R rardnn Grove ZONE Type ✓ Group _9
CONTRACTOR Colegrove, Inc.L IC.NO. 167293 APPROVED DATE
ADDRESS 419 E. 17th St., Costa Mesa. ZONING
LEGAL 'LOT I 2822 ZONE NO.OF USE OF NEW f/)
DESCRIPTION NO. 122 BLOCK TRACT �/ I PLANS O I BUILDING //1//rf J
A.P.NO. APPROVED /,' DATE g/-/rS
SIZE [[�� NO.OF SLOGS. [�
EVES
OF LOT 60 x 104. NOW ON LOT {LOnp REQUIRED ALLOWED
USE OF (CENTER LINE ST.)
EXISTING BLDG. nfnp FRONT re? FT. IN.
SETBACK LINE FROM nn
CENTER OF STREET 581 REAR YARD 2AI R.SIDE (S FT. IN.
SIDE YARD I LEFT 51 I RIGHT 52 L.SIDE ) FT. IN.
DESCRIPTION OF WORK P.REAR a--0. r FT. IN.
NEW I X II ALTERATION I II ADDITION I
REPAIR I II MOVING I II DEMOLISH I
SIZE BUILDING NO.OF
1356 ROOMS 6 STORIES 1
EXTERIOR WALL ROOF
COVERING Star DO I COVERING Rock
USE OF BUILDING AND WORK TO BE PERFORMED •
Single family residence with
attached double garages .
Plan 110 C.
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'......../%7C.. PERMIT PERMIT FEE $ 32.00PERMITTEE /� ✓
PLAN CHECK $ 16.00
$ X3'715
AUTHORIZED AGENT Dike & Colegrove, Inc.
N
TOTAL FEE 5 48,00