HomeMy WebLinkAbout3066 HAYES AVE - Building PermitsSuite:
Vicinity: ROOF
Primary Occ: R3 Dwellings/ Cong Res �10
Parcel Number: 14172107
npplicant: RAMSEY, RANDY
Address: 31131 SANTA MARGARITA
SAN JUAN CAPISTRANO, CA
Owner: ZACHARY, IKE TR
Address 3066 HAY�S
COSTA MESA, CA
Contracror: RAMSEY ROOFWG
Address: 31131 SANTA MARGARITA
Arch :
Address:
Zip:
SAN JUAN CAPISTRANO, CA
Zip: 92675
Phone:
License:
Type of Conslruction: V-N
Zoning: R1
�Phone: 949-240-7934
Zip: 92675
Phone:
Zip: 92626-2858 -
Phone: 949-240-7934
License: 847175
Eng:
Address:
ISSUED BY:
Applied: 10/12/2005
Issued: t0112/2005
Phone:
License:
SCOPE OF PERMIT
TEAR OFF EXISTING ROOF. INSTALL 1 LAYER OF 30# FELT, 30 YEAR COMPOSITION SHINGLES AND REPAIR/REPLACE SHEATHING AS
NEEDED. 3,000 S.F. INCLUDES ATTACHED GARAGE.
FEE SUMMARY
Plan Check: $0.00
Permit: $125.25
SMIP Res: $0.60
SMIP Cam: $0.00
Other: - -� $0.00 "
Inspection: $0.00
Total: $125.85
PLANNING & ZONING
SETBACKS
MAINSTRUCTURE Front 0-0
ACCESSORY Front p-p
PARKING Existin : 0
Rear 0-0
Rear 0-0
Reauired: 0
Lefl 0- 0
Lek 0. 0
-- Pr000sed: 0^-.
Calc Valuation: $s,000.00
Claim Valuation: ss,000.00
Right 0-0
Right 0-0
NO710E: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related
ragulations. (Ord. No. 92•2B, § 1, 12-21-g2)
EXPIRATION: This permit shall automatically ezpire and become void if work is not commenced within 1B0 days, or if work Is suspended or abandoned
for e period of 180 days.
INSPECTIONS: In order for ihe work authorized under this permlt to be considered legal, such work must comply with all applicable codes, and all
requlred Inapeetlons and final approvel must be obtained. Failure to obtein inspections.and final approvel will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 75q-5626
244&4819�00�
WORKERS'COMPENSAnON DECLARAPON: - �
I hereby attirtn untler penelry of perjVry one ot the tollowing declaratlons: , �
❑ I heve end wlll malntain a certi�iwte of consent to sell-Inswe for workers' compensation, es provided for by sectlon 3700 of ihe Le6or Code, for t�e peAortnence ot ihe �
work tor which this pertnit is issued. �
�^.r -.
J I have and will maintain workerY,:, �pensa�ion insurance, es required by section 3700 of the Labor Code, for the peAormance ot the work far whiU this permit is issued. �
f�3-My"work�ers'�Q m�pensaj'wo Insumn wrrier end poliry numher are: ^-' �' QO �^ ��
��� '��"c ZT 1_ n� � f; ?!?
C_alrjer. .JrA. --u�N .,-...__ PortcyNumEec``( W �C
�riM1is section need not be wmp/eted �l the'pertnif is�velueC et one hundreU tlallars (S 100 or less.) �`—
'; '✓ ��Hc� '7 ���
❑ I certity that in the pertortnanc9 of IKe work foUwhic� thl;�p&mn��i issueQ��sha t employ eny person in eny manner so as to become sublect to the workers'
compensation laws oi Californie, antl egree that If I shoulC'bec�e sub�e�lK�orkers' compensetlon pmvislons of Section 3700 of Ihe LaCor Code, I shell torihwith
�ply_with Ihese visions. C� O G L ^'`, S
�icantS�re:.-'�`��� L D�ate �--.��:I,� � �-w
WMAING FAILURE TO SECURE WORKE ' PENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLO ER TV O CRIMIryp1 PENALTIES AN� pVIL FlNES UP TOONE HUNORED
THOUSANDOOLLARE�$100,000),INADDITI TOTHECOSTOFCOMPENSATIIXJ,DAMAGESASPROVIDEDFORINSEGTION31080FTMElABORWDE,IMEREST,AN�ATTORNEVSFEES.
LICENSED CONTRACTORS DECLARATION:
of Chepter 9(commencing with Section 7000) af
and Profesyons Code, and my Ilcense is in full
CONSTRUCTION LENDING AGENC�:
❑ I hereby ettirm thet there is a construction lentling agency tor the peAormance of the work br which Ihis permil is iuuetl. (Sec. 3097, Civil Cotle).
LBntlefS Name:
Signeture: _
OWNER-BUILDER DECLAiiATIONS:
Lenders Adtlress:
Date:
I hereby eNirm ihet under penalty ot perjury Ihat I am EXEMPT FROM 7HE CONTRACTORS LICENSE LAW for ihe following reason (Sec. 7031.5, Business end Professions
Code: Any ciry or county which requires a permit to construct, eller, improve, demolish, or repair eny structure, Prior �o Its issuance, also requlres ihe epplicant for such permit
to file a signed statement t�et he or she Is Ilcensed pursuent to Ihe provisions oi the Contractors Llcense Lew (Chepter 9(commencing with Sectlon 7000) of Divislon 3 of the
Business end Professions Cotle) or Ihat he or she is ezempt therefrom end the basis for the elleged ezemption. Any violation oi Section 7031.5 by eny epplicant Por a pertnit
subjects the epplicant to e civil penalry of not more ihan live huntlreC tlollars (5500).):
❑ I, as owner ol Ihe pmperty, or my amployees with weges as their sole wmpensation, WILL DO 7ME WORK, end the s�ructure Is not intentletl or oflered tor sale (Sec.
7044, Business antl Professions Code: Tha Con�rectors LJcense Law tloes not apply to an owner of property who builds or improves Ihereon, end who does such work
himself or herself or through hi5 or her own employees, provided Ihat such improvements ere not intended or oMered for sale. If, however, t�e building or improvement is
sold within one year of completioq the owner-builder will heve Ihe burden of proving iha� he or sha Aitl not build or improve for purpose of sele.). •
❑ 1, as owner of Ihe property, am E%CLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to wnsWc� Ihe pmject (Sec. 7044, Business antl Pmfessions
Code: The comractors License L.ew tloes not apply to en owner oi pmperty who builds or Improves Ihereon, entl who contracts tor such pmject with e conirector(s)
license pursuant to the Contrac�ors License Laws.).
❑ I em exempt under sec. Business entl Professions Code for �his reason:
Signature: Date:
Owner ID veniietl by Odvefs license. ❑ �es ❑ No Drivers License No.
Verificetion oi Ownarship by (rype ot dwument, i.e. - property tez 6ill or deedJ:
Expires:
DIVISION OF INDUSTRIAL SAFE7Y PERMR CERTIFICATION:
❑ I hereby certity that no ezcavetion five (5) or more feet in depth into which a person is requiretl to tlescend, will be meCe in connection wlth work euthorized by this
permii, antl Ihat no building siNcture, scettolding, felsework, or tlemolition or dismantling ihereot, will be more �hen ihirry-six (36) teat hig�. (Chap. 32, Grp 2, ArI 2, Sec.
341, Tltla B, California AtlminisCrative Cotle).
❑ As owner-builtler, I will not emDloy enyone to do work which woultl require a permit trom the Division ot Industrial Safery, es notetl ebove, unless such person has e
permit to do such work trom thU division.
Signaiure: Data:
Division ol Industrial Salery Pertnit Number:
CERTIFlCATE OF COMPLIANCE AND AUfHORVJ1T10N OF ENTRV: I certify under penalty of perjury �hai I have reatl �his appliwtion end state Ihat �he infortnation given is
wrrecL I egree lo comply with all st8te lews and city oMinances relating to building construction, end euthorize represeniatives oi lhe CIry ot Costa Mesa to enter upon Ihe
ebove-descnbed property for inspection purposes. I agree not to occupy ar allow occupanty of eny building euthonzed by this pertnit until tinel Inspection.
CODE I, INSPECTIONTYPE
1fi16 Fixed System Final Fire Pre�ention
1266 Pool Spa Fin01 .
200 Finel Re-Rool
201 Finel BIxWRetaining Wall
202 Final FectOry Fire Place
203
204
Finel Sign
FinaPDemolition
Pdg � .. IllID18Li
1-�1—"= �
CODEi INSPECTIONTYPE
206 Flnel Mechenical
208., FInelPlumbing
210 Finel Elecincal
212 Finel Fire Preventlon
220 Final Planning Approval
222 Final Site
250 FInalBullding/Occupancy
�
PAIE II�LL@
Avguat 3, 1970
�
I�h�. Ike Zachary � � .
3066 8c�yes Avenue �y
Costa t�Feas, C�,].ifornia
Dear Sir:
A building permit hae been issue o,8ir Poole to coastruct a
private sxi�ing pool on your property. -
In orfler that your 1 vill be a saYe one aad Yor the purpose
of advising you oY yo�a re sibility regsrding the requirementa
of the Costa N6asa Municipal , we refer you to 6ection 8107, a
copy of ehich ie attached.
Thie lette e direoted to you.in order that you xill be eprqre
of our ordivauce d can meke a complete safety check of your pool
area. >
� ' Sincere]y yours,
RICHARD HANHART
Builflis� 3afety Dlrector
RH:dh
7�
� 2
2
2,�,'�� i I � 4F�,
`��� � �' , �'' '' � °Z
TESTING
Laboratories �j ��,«t�=t.,. ���<<f�o=,=«�, �,��.
. — --
. o eor. <� .,;�o <���c�' wAv . iouc, ee�e� UIiF. e060� •�7U� <7c�3755 . 2�7� c3o�23Eb . �]I�) 828�6+52
?waC� C=4 �ES
:1� U'. - r 5'.e. Nen Oet e.. �q
Sa-�e�nG~c ecDOl 1a55Gem+aan.e oO80..1
I���' S'� ?G•5 . .� ac+ C�'� v0601 �:�1� eJe 119e
August 19, 1970
Examination: SC70-4959
COMPRESSION TESTS ON GUNITE CYLINDERS
L. E. Sprague
2133 Miramar Drive
Balboe, Celifornia 92�61
PROJECi
ADDRE55
SAMPLE FROM
�RCMITECT
ENOINEf■
MIX
DATE CAST
DATE TESTED
CYLINDER NO.
COMPRESSION
TOTAL LOAD, LBS.
POUNDS PER SO. IN.
COMPUANCE
S�+inming Pool for IKE ZACHARY
3066 Hayea Ave., Coeta Mesa
Shsllow end 0 bond beam - deep end
CONT�/1CT011
Sir Poola
suscoHTe�cro�
Grove Gunite
SPECIFIED
Gunite STRENGTH
8-12-70
8-19-70
SEi
7' �ya
95.000
3,3F0
8-19-70
BB2
7-nays
92,500
3,270
8-19-70
DES
7-nays
98,000
3,465
7-Aay test compliea with specifications.
MAD( �Y DEIIVERED er
CYLiNDERS ' LoE, Aprague L.E, Aprague
��,%�=�-z�- 7��
DIST[I�UTIOM:
L. E. Sprague
Permitf� 32125
Contract;� 3246
2,000 psi
5"
SE6"HOLD" 8B4"HOLD� DE6"HOL
lECEIVFD ON
8-13-70
��c��P����
BUILDING SAFETY DEPT.
su P°°le AUG 2 0 1970
1015 N. Parker, Orange � �,M
Coeta Mesa Sldg. Dept. �5�����1J,lli1'1,3i2��i4�5'a�
G��Y��' `
•LL N(POoiS �RE fVlMITIEO �5 iM[ �ON�IDCNTI�I V40YENTY Of CIICMTS, �IITNOMI3�TIOH �ON ✓VlLIC�T Of pUN REP04T5, COMCLUSIOMS. 04 Ci�
TR�CTS �POM OR 9fG��01YG �wf� �5 o[S(RV[O IEN�IMG OVP WNITTCN �PVNOV�L �S � 4UTll/�t VROTECTIOM TO CLIEMTS. TME VVlLIC �MD OUM6[lVES.
330�2
OWNER ���Y� I� DATE 7-31-70
JOB ADDRESS 3066 Hayes Avenue BUILDING PERMIT N0. q2125 -
i�
SUBCONTRACTOR
ROUGH PLUMBING
PROP. $WR. LINE Q HOUSE CON.
SPRINKLING SYSTEM
MISCELLANEOUS Q�/�{r,/��
ROUGH HEFTING ANO�AIR CON�ITI01'ING �
TEMPORARY SER q
UNOERGROUND POwER � �
ROIIGH WIRING
TRENCHES � FORMS � STEEL REINF.
FLOOR SVSTEM
FRAME ANO FLASNING
LATMING - IN [-J OUT n
PLASTER, BROWN COAT
STRUCTURAL, FINAL
HEATING, VENT., REFRIG. AND A.C., FINAL
PLUMBING, FINAL ANO GAS TEST n
ELECTRIC, FINAL
BUIL�ING, FINAL
DATE'
JOB ADDRESS 3066 Hayes Avenue BUILDING PERMIT N0. 32190
GENERAL CONTRACTOR Owner-Rui Idar DESCRIPTION of WORK o.,r ni..,.�, cr,.t i
AP No. 141-721-07 LOT 6 TRACT 594(1 FIRE ZONE
SUBCONTRACTOR
W ATER
ROUGH PLUMBING
PROP. SWR. LINE � HOUSE CON. �
SPRINKLING SYSTEM
MISCELLANEOUS
ROUGH NEATING ANO AIR CONDITIONING
TEMPORARV SEHVICE OR POLE
UNDERGROUNO � POWER �
ROUGN WIRING
TRENCHES FORMS � STEEL RE
FLOOR SYSTEM
BON� BEAM � STEEL REINFORCE [
SMEATMING
FRAME AND FLASHING
LATHING — IN �J OUT ❑
PLASTEfl,BHOWN COAT
STRUCTURAL, FINnL
HEATING, VENT., REFRIG. RNO A.C., FI
PI.UMBING, FINAL ANO GAS TEST r]
ELECTRIC, FINAL
BUIL�ING, FINr1L
,,
',' ' ' .: 2 I 25
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O.BOX1200 COSTAMESA.CALIFORNIA92626
Z
a cwj
Z
ZQ
� N
am
J �
J N
aw
�] J
J m
Q
U N
Z Q
w �
aw
WZ
J Q
m Z
J �
W w
O
ZH
w�
��
�o
JU�7RPA�D002677# *��**
crisn 34.5C•
APPLICATION FOR BUILDING PERMIT
For Applicant to Fill in Completely RECEI sv DATE RECEIVED DATE ISSUED
BVILDING � / I � �
ADDRESS o66 Ha e$
j PERMS f�lq�
OWNER Ike ZACYSATy A.F. NO. o•Z/ ot
ADDRESS yes Ave. 545_7 80 BUILDING /1 f� �
3066 Ha ADDRESS�)Q(if(� ti� I
TEL. TRACT 4O LOT 6 BLOCK
CITV �.O$t.8 Messa NO.
CANSTRUCf10N U7i�'lOWYl W A P
LENDEF
x
BFANCH
OWNEPIke Zachar
ADDFESS VALUE
ORENGINEER Tebault TEL ,L� 18 S • Swimmin • Pool S
�} FIRE
ADORESS1JO�1 PTOSpeCY.� S$21t.8 n$ ZONE TVPE GROUP
CONTRACTORSST POOZS ByPROVED / `DATE ��/- //
AODRESS1OlS N. Parker
TEL. Z�N NO.OF USE OF NE
C�7y Orange No. $38_006 �/ P�'�' BUILDING
STATE CITV VARDSAPPROVED VARDSAPPROVED
���. No. 230261 LIC. NO. '�Q 1 MAIN BUILDING ACCESSORV BUILDING
SIZE /� NO.OF BlDGS. (FROM C/lSTREET)
OF LOT (� NOW ON LOT FPONT FT. FT.
USE OF
EXISTING BLDG. FT
SIZE OF NO. OF
NEWBLOG. ROOMS STORIES L.SIDE FT. FT.
EXTERIOP WALL Ii00F
COVEFING COVEflING REAR FT. FT.
USE OF BUILDING AND WOFK TO BE PERFORMED DISTANCE BET. BET. MAIN &
MAIN BLDGS. ACCESS. BLDGS.
y VAR.3Y+ DATE
C.U.P.3y+ APPROVED
APPROVED u / � O
I horeby ocknowletl8e that I huve reetl this applicotion entl state
that t�a abave informetion is correct entl o8�ea to comply with
ull Inws roguleting buildinB consttuction, antl I shell not emplay
any parson In violatiOn Of the workman's compansation laws of
the State of Californie.
I horoby cartity thet I em proparly Iicansotl as o contrector untler SQ. FT.
rhe Steta of California Businass antl Profossians Cotle, Dlvisicn 3, THE AMOUNT SHOWN UNDER VALVATION IS FOR
Chepter 9, entl that such licenxs era In f�il force antl effect, or I THE PURPOSE OF ESTAHL6HING A PERMR FEE ONLV:
am exampt from tne provisions of the Stero of Calitornla Business VALVATION
ontl Profes51an5Cotle, Division 3, Chap[er 9. Z 3�0�
/ n PERMIT FEE 5
SlBnotureof �y� y ^ /y/D� %
Patmittae �C �LP�J $�,�U 6 PLAN CHECK $ !� S O
Authorizetl Agent TOTAL FEE $� � V�
m
M1
7'
m
E
LL
•:., 2396h
r� A �
�� COST.� MESA BUILDING-SAfEfI' DEPARTMENT
P.O.BOX 917 COSTA MESA.CALIFORNIA
For Applicanf to Fill In Completely
TYPE OR PRINT
ADDRESS�� 6:P �
COSTA MESA, CALIFORNIA
OWNER CC{Y Land Com an
MAIL 1304 19. Commonaealth Ave.
ennwras
cirv Fullerton� Calif.
LIC.TNO. 19O'}ST NO. $%1�271�
SIZE �� I NO.OP BLOOH. O
OF LOT � NOW ON LOi
USE OF
EXISTING BLDG.
9ETBACK L�NE FROM ' �J �
CENTEP OP BTPEE! D REAR YARD /c /
SI�EYARD) LEFT 7 I R16HT � �
J
DESCRIPTION OF WORK
BUILOIN6� " 6,' NO.OP
SIZE �� ROOM9 � 6TORIEH 1
EXTERIOR WA ROOP
COVERING �tUCCO GOVERIN6 S�13IIgI0
USE OF BUILDING AND WORK TO BE PERFORMfiD
Tract 5340 — Lot 6
Plan 612FR
R-1 Reaidence � �
I HEREBY �CKNOWLEDOC TM�T I NAV6 qCAD Tl11 APPLIGTION
ANO 6TAT8 THAT TH6 ABOVH IB CONRECT AND AOqBE TO COM�
PLY WITH ALL CITY OHOINANC88 ANO BTATH LAWe qBOUTATINO
OUILDINO CON9TRUCT�O
SIGNATURE OR ���w�_ �/_
PERMITTEF
AUTHORIZED A6ENT
CITY Or C�STA M�S�A
MAY 5 1965�
APPLICATION FOR PE
BY
ZONIN(i
NO.OF 11860P
PLANB � OU�LO11
YARDSAPPROVED
MAIN BUILOIN6
VAR. �C
J
BE LESS THAN
YARDSAPPROVED
AGCESSORY BUILOIN6
I.hY��
TH¢ /�MOUNT 9NOWN tINO¢R VALUATION 19 FOR TH8
PUPPO6H OP fiBTABLIfiHINO A PBRMIT p88 ONLY.
VALUATIOfJ � /'c
PERMITFEE $ ('f /
$%��S�Z
TOTAL FEE � / d 3
�� : . ��. �2 i so
, COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O. BOX 1200 COS7A MESA, CALIFOFNIA 92626
For Applicant to Fi!l in Completely
BUILDING .� � � � i / _ n
Z .
a cWj
� Z
ZQ
O c~i�
am
J �
J V1
Q W
[t] J
• Q1
J Q
UN
2a
W ¢
aw
wz
J Q
m Z
J �
W W
O=
Z �
W �
� O
�
z
Q
U
J
1
a
Q
0
H
N
Z
O
F
U
�
�
�
�
z
OWNEP �
MAIL
ADDRESS_ �/
CITV
CANSTRUCT��N
LENDEF
BRANCH
ADDRESS
ARCHITEGT
AODRESS
CITV
STATE
LIC. NO.
SI2E
OF LOT
USE OF
EXISTING BL
SIZE OF
NEW BLDG.
EXTERIOR w
COVERINfL
USE QF BU�
TEL.
NO.
CITY
LIC. NO. .
NO.OF BLDGS.
NOW ON LOT
NO.OF
ROOMS STOF
ROOF
COVEfiING
AND WORK TO �E PERFORMED
AUG . ��OLNSAoO �IZ7 o*,a+a,tn5.0�
APPLICATION FOR BUILDING PERMIT
RECEIVEDBV D TERE EIVED DATEISSUEI
_ 0 9�._M
A.P. NO. / � � � U � ��//1 I7 / L
BUILDING �O�/ Y���i �
ADOFESS (D %/
TRACT .S�YO LOT [� BLOCK
OWNER
FIRE
ZONF
APPR
E NO.OF USE OF NEN✓� , �/fL
/ PLAN$ -� BUILDING (.�
VARDSAPPqOVED VARDSAPPROVED
MAIN BUILOING ACCESSORV BUILDIi
FROMGLSTREET) � �/I.
'.Rl1f�T fT CT
VAR. a{`+
C.U.P.�s
BET. � BEf. MAIN &
I hereby aCknowlatlBa [ha[ 1 heva �Batl [his eOPlice[ion antl stote HO�,D FOR SPECiA KCVU�Kc.""r."�' •
[hat the obovo intormniion is correc[ ond aprev to comply with
nll luws raBulncin0 builtlinp conzcruction, nntl I shall not employ
any parson in violotlon ot [�e wo�kmpn's compensatiOn laws Of
tho Stato o( Colifornie. . �
I heraby cert�fy thot I em properly licensetl as a convactor antlor SQ. FT, o
[he State ol Celifornia Business antl Professlons Code, Divisicn 3, THE AMOUNT SHOWN UNDER VA�V.4TION IS FOF �
Chapter 9, antl that svch 17tenses ere in fulf force anC eftect, or I THE PUFP�E OF ESTqgL6NING A PEFMIT FEE ONLY: o
am ezempt irom [he provisions of tha State of California Buzlness �
VALVATION
antl Protoszions Code, Division 3 ChaPter 9. ' Q r
PERMR FEE ]
SlBnaturo ol J�{ �) m
Permittce � � 4J�o `�— PL4N CMECK 5 -� E
�0 �
Au[horizetl A6ant LL
TOTAI FEE
COSTA MESA BUILDING—SAFET" DEPANTMEMT 297 6%22/79 6.00 TL''
� P.O. BOX li .�. .� _,
• Costa Mesa, California
CONTRACTOR Pacific Installers, Inc.
Address 75(y1 pnthony Avenue
�i� Garden Grove , CA Zip Code 9261
Swte Lieense No. p11898 ��au. Bl
City License No. 59� Tel. No. 839— 7 i
VUMBER TYPE OF FIXTURE OR ITEM FEE
Floor
6ar
Kitchen
Basin (Lavato
Closet (Toile
in¢ Pountains
Heaterand Vent
BackOow Reventer
Lawn $prinklers (Res or
Property Sewer... Feet
House Sewer Connectiur
Cess000l. Seo[ic Tunk
Miscellaneous
TOTAL FEE
CMF 0450-46
�m
TRAGT NO. RECD. BYj,�_ % � �� � �
LOT NO. OATE IB6U6D
BVRDING USE //����
L%
Address �
Owner �C� h ��—A
naa.�ss �0.1�r�����i��
1 hereby acknowledgeithat:l have read this applica[ion and
state that [he above is cotre`cl and agree to comply wilh all
City Ordinances�and Stafe'Laws regula[ing plumbing.
1 certify,Ihat�Ypossess Ihe above valid Shte of Califomia clasu-
fication or�1 am [he legal owner of Ihe residential property dr
uribed�above.
1'certify that I have obtained a permit from the S[a[e Division of
IndusVial Safety for escava[ions, o[her lhan swimming pools, five
feetdeepordeepeca di�wh�aperson' requiredtodexend.
Signaiure of
Permittee \
INSPECTION RECORD
APPROVALS
IMlIECTOR