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Home My WebLink About771 HUDSON AVE - Building Permits� BUILDING PERMIT Job Address: 771 Ht1DSON AY Suite: Vicinity: RESIDENCE AND ATTACHED GARAGE Parcel Number: 14152305 Applicant CHACON, JOSE Address: 1142 N BOMO KORAL CIR SANTq ANA, CA � Owner: MAC MILLAN, DENNIS L TR Address 771 HUDSONAVENUE COSTq MESA, CA Contractor. . CAL STATE ROOFWG Address: 1742 N BOMO KORAL CIR SANTq ANA, CA Zip: 92703 Arch : Address: Zaning: R1 R1 Phone: 714-813-7736 Zip: 92703 Phone: Zip: 92626-3006 Phone: 714-813-7736 License: 801616 Eng: Address: ISSUED BY: Status: ISSUED Applied: O6/29/2004 Issued: 06/29/2004 Phone: Phone: Zip: License: License: SCOPE OF PERMIT TEAR OFF EXISTING COMP SHINGLE ROOF. INSTALL SHEATHING, FELT AND COVER WITH 30 YEAR COMP. INCLUDES ATTACHED GARAGE. Plan Check: $0.00 Permit: $11125 SMIP Res: $0.50 SMIP Com: $0.00 Other: $0.00 Inspection: $0.00 Total: $111.75 SETBACKS MAW STRUCTURE Fronl 0-0 ACCESSORY Front 0-0 PARKING Existina: p Rear 0- 0 Rear 0- 0 Required: 0 FEE SUMMARY PLANNING & ZONING Left 0- 0 Left 0- 0 Proposed: 0 Calc Valuation: Claim Valuation: Right 0- 0 Right 0- 0 sa,sso.00 $4,950.00 N07lCE: 7he work authorizeq by this permit shall comply with all applicable handicap access requiremertts under California statutes and related regulations. (Ord. No. 92-28, § 1, 1241•g2) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 1 BO days, or it work is suspentled or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be consideretl legal, such work must comply with all applicable codes, and all requlred Inspections and flnal approval must be obtained. Failure to obtain inspections antl tinal approval will result in the expiration of Ihis permit. FOR INSPECTIONS CALL: (71q) 7545626 !6aW8 (&N0) WORKERS' COMPENSATION DECLARA710N: I hereby eNirtn untler penalry of perjury one of the tollowing decleretions: ❑ I have nd wlll"malntein a certificate ol conseN co self-Insure tor workers' compensation, as provided for by sectlon 3700 of the Labor Code, for tha peAormance of the ar which Ihis permlt Is Issued. I have end wlll maint 'n workers' compensation Insurance, es required by section 3700 of the Labor Code, for ihe pedortnance of the work for which Ihis pertnit Is Issuad. My workers' wmpe�atlon Insurance carner and pollcy number ere: Carrier: � Policy Number: (lh/s secf/on need not be comp/eted i/ the Dermit is valued et one hundred aallars ($700) or less.) ^ v ❑ I certify thet In the pertortnance ot ihe work for which thls permit is issued, I shall not employ eny parson in any menner so as to become subject to the workers' compensetlon laws of C� ifomia, and agree that If I shoul0 became su6�ect to Ihe workers' compensatlon provisions oi Sectio 3700 ot the Labor Code, I shell forthwlth cwnplywiththeseprov5i ns. ��^�/ / O�� Appliram4Slgnaturer—~� Date: �� L— � WMNIN(3: FAILURE TO $ECUR ORKEiiS' COMPENSATION COVERAOE IS UNUW Fl1L PND SHALL SU61EC� AN EMPLOYER TO CRIMINAL PENALTIES AND GVIL FlN S UP TO ONE MUNDRED TFIOUSAND DOLURE (5100,000 I ADDRION TO THE WST OF COMPENSAiION, DAMAGES AS PROVIDED WR M SECiION 31060F THE IABOR CODE, IMEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby aHirtn Ihat I am licensed under provisions oi C�apter 9(commencing with Section 7000) of Division 3 of the Busineu end Professions Code, entl my Ilcense Is In tull force end eflect. Llc. x /l Class M . /_ . L — . Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby aHirtn that ihere is a constmction lending egency tor the pedormance of ihe work for w�ich Ihis permit is issuetl. (Sec. 3097, Civil Code). Lender's Name: Lentler's Address: Siqnemre: OWNER•BUILDER DECLARATIONS: Date: I hereby aHirtn thei untler penelry ot perjury thai I am E%EMPT FROM THE CONTRACTORS LICENSE lAW for the following reason (Sec. 7031.5, Business entl Professions Cotle: Any ciry or counry whic� requires a permit to construcL elter, improve, demdish, or repair any structure, prlor to its issuance, also requires the ep0licant for such pertnit to file e signed stetement that he or she is Ilcensed pursuant to the provisions of tha Conirectors License Law (Chapter 9(cammencinq with Section 7000) ot DlWsion 3 of ihe Businoss entl Prolessions Code) or that �e or she is exempt theretrom and Ihe basis tor the allaged e:emption. Any violation of Section 7031.5 by eny applicant lor e permit suhjects the eppliceni to e civil penalry ot not more then five hunCred tlollers ($500).): ❑ 1, as owner ol Ihe property, or my employees wl�h weges es iheir sola compensation, WILL DO THE WORK, end Ihe siructure Is not intentlatl or oflerad lor sale (Sec. 7044, Business end Professions Code: The Contractors Litense Law tloes not apply to an owner of propetly who builtls or impmves Ihereon, antl who does such work himsetl or herseli or ihrough his or her own employees, provided that such impmvements are not Intended or oMered lor sale. tl, however, ihe bullding or improvement Is sold within one year of completion, the owner�6uilder will have ihe burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ I, as Owner Ol lha propetly, em E%CLUSIVELV CONTRACTING WITH LICENSED CONTfiACTORS to conslruc� �ha projett (Sec. 7044, Business and Profes5ions Cotle: The contrectors License Law aoes not appty t0 en owner of property w�o builtls or Improves Ihereon, entl who conlracis for such pmject with a contraCtor(s) license pursuant to iha Coniractors License Lews.). ❑ I am exemp� under sec. Signature: Owner ID venfied by drivers license. ❑ Yes ❑ No Busine55 and Profession5 Code tor t�is rea5on: Vedflcetian of Ownership by (type of tlacument, i.e. - properry tex bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATON: Drivers Licensa No. Date: Expires: ❑ I hereby certily that no excavation five (5) or more feet in depih into which e person is require0 to descend, will be matle In connection with work authonzed by �his permit, and that no building strucWre, scaHolding, lalsework, or demolition or dismamling ihereof, will be more than thiny-six (36) feet high. (Chap. 3.2, Gry 2, An 2, Sec. 341, Ttle B, Celifomia Adminisirative Gode). ❑ As owner-builder, I will not employ enyone to do work which would require a Dermit from Ihe Division ol Intlus�nal Salety, as noted above, unless such person hes e permit �o do such work from the division. SigneWre: Dete: Division of Industriel Setety Pertnit Numbar: CER7IFlCATE OF COMPLIANCE AND AUTHORRATON OF ENfTiV: I cenity under penelty of perjury that I have reatl this epplication and state Ihat Ihe informetion given is cOrmct. I egree to wmply wlth all state laws end city ordlnences relating �o building consimction, end authorize representailves of ihe Ciry ot Coste Mesa to enter upon t�e ebove-describad properry for inspection purposes. I agree not to occupy or allow occupency of eny building authorized by this permit until final inspection. COUE I, INSPELTIONTYVE 1676 Fixed System Final Fire Prevention 1286 Pool Spa Final 200 Final Ra-Roof 201 Final Block/Retaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demalition Qsj& IMRIRLS �� n. , 1 .. CODEA INSPECPONTYVE 206 Final Mechanlcal 20B Final Plumhing 210 Final ElectdCal 272 Final Fire Prevention 220 Final Planning Approvel 222 Final Site 250 FinalBuilding/OctuDanty � � a i ' (714) 754-5273 • Faz (714) 754-4856 • www.d.COSfa-mBSa.Ce.US 77 FAIR DFiNE, GOSTA MESA, GA 92626 BUILDING PERMIT ,lobAddress: 771 HUDSONAV Suite: Vicinity: FOUNDATION REPAIR Parcel Number: 14152305 Applicant: HERNANDEZ, LUIS Address: 1411 BORCHARDAVE SANTA ANA, CA Owner: MAC MILLAN, DENNIS L Address 771 HUDSON AVE COSTA MESA, CA Contrecror: ULT�MO ORGANIZATION INC Address: 1417 BORCHARD AVE SANTA ANA, CA Zip: 92705 Arch : Address: Stalus: ISSUED Applied: 07127/2001 Issued: OB/21/2001 Zoning: R1 R1 �— ISSUED BY: Phone: (714)560-8999 Zip: 92705 Phone: Zip: 92626 Phone: (714)560-8999 License: 338922 Eng: . � Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT FOUNDATION REPAIR FOR EXISTING SINGLE FAMILY RESIDENCE. Plan Check: $254.31 Permit: $39125 SMIP Res: $2.50 SMIP Com: $0.00 Other: $0.00 Inspection: $0.00 Total: $648.06 SETBACKS MAINSTRUCTURE Front 0-0 ACCESSORY Front 0- 0 PARKING Existinq: o NOTES: Rear 0-0 Rear 0-0 Required: 0 FEE SUMMARY PLANNING 8 ZONING Left 0- 0 Left 0- 0 Pro osed: 0 Calc Valuation: Claim Valuation: Right 0- 0 Right 0-0 525,000.00 $25,000.00 NOTICE: The work authorized by Ihis 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 perlod 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 Inepactione 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) 7545626 2648d8�btl0) WOflKERS'COMPENSATONDECLARAnON: I hereby aHirm under panelry of perjury one oi tha tollowinq declara�ions: ❑ I have entl will maintain e certiticete of consent to selt-Insure for workers' compensetion, es provldetl for by section 3700 of the Labor Cotle, lor Ihe pertormance of the �ork Por whiCh Ihis permit IS i55uetl. have anC vnll malntein workers' compensa6m insurance, as required by section 3700 of ihe LeDor Code, for Ne peAormance ot Ne work for which Uis permlt Is Issued. My warkers' compensation Insuranca carrier and poliry number are: �_ �L Cerrier. �%�1�77—' �i9 M/% //�JS/ 1,PL}�fC`b �'Zi.U� Policy Number. � �7 C (This section neetl nof be comp/eteU il the permit is veluetl et ane hundred dWlars ($100) or less.) , ❑ I certiy that in the peAartnance of the work Por which this pertnit is iSsueQ I s�all not employ any person in eny manner so as ro become subject to the workere' compensation laws at Celifomia, en �that H I should bewma subject to Ihe workers' compensation proWsions ot Sectlon 3700 of the Labor Code, I shall fotlhwith comply with ihese provisians. -pJ ApplicentSlgneWre: C Dete: �/�J/O��/�/ WARNINO: FAILURE TO SECURE WORKE ' COMPENSATIO VERAGE IS UNLAWFUL AND SHALL SUBJEGT AN EMPLOVEF TO CRIMINAL PENALiIE AND CIVIL FlNES UP TO qJE HUNDPED T/KKISAND DdlARE (5100,000), IN ADDIiION TO THE COST OF COMPENSATION, DMtAGES AS PROVIDED FOR IN SECTION 37060F THE IABOR CODE, IMEREST, AN� ATTORNEV'S FEES. LICENSED CONTRACTORS DECLARA710N: I hereby eMirm that I am Ilcensed under p ovisio tome an0 eltect. Lic. a�� Conirecrols Signature: 9(commencing with Section 7000) of Dlvision 3 oi the Business and Professions Code, end my Iicensa ISIn full � Class a if,lT— Date: CONSTRUCTION LENDING AGENCY: � I hereDy aRirm ihat there is e construction lending agency for ihe OeAormance of Ihe work for which this pertnit is issued. (Sec. 3097, Civil Code). Lendefs Neme: Lendefs Atltlreu: Signatura: OWNER-BUILDER DECLARATONS: Oate: I hereby effirm that under penalry ot perjury ihat I am EXEMPT FROM TME CONTRACTORS LICENSE LAW for the lollowing reason (Sec. 7031.5, Busineu end Professions Code: Any ciry ar counry which requires e permit to consiruct, alter, improve, tlemolish, or repair any structure, prior to its issuanca, also requires Ihe appliwnt for such permit to lile e signed statemen� ihat he or she Is Iicensetl pursuent to the proNsions ol Ihe Cantrectors License Lew (Chapter 9(commencinq with Section 7000) of Divislon 3 of t�e Business entl Prafesslons Code) or Ihet ha or she is exempl therefrom and the besls for the allegetl axemption. Any vlolation ot Section 7031.5 by eny applicant tor e pem+' subjects the epplicant to a civil penelty oi not more than tive hundred dollers ($500).): ❑ I, es owner ol ihe proDerty, or my employees with weges as their sole compensatlon, WILL DO 7HE WORK, antl tha sWCNre Is not intentletl or ofleretl br sale (Sec. 7044, Business end Professions Cotle: The Coniractors License Lew does not appty to en awner ot properry who builds or improves ihereon, antl who does such work �Imsetl or herself oi through his or her own employees, provided ihat such improvemenis are not Intentled or oflered for sale. If, however, Ne building or Improvement is sold within one year ol completion, �he owner-builder will have ihe burden oi proving ihat ha or she did no� 6uild o� improve for purpose of sale.). ❑ I, es owner of tha property, am E%CLUSIVELY LONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Prolesslons Cotle: Tha wntractors License Law tloes not apply to an owner ol property who bullds or Improves thereon, end who contracls lor such pmject with a comractor(s) license pursuanl to Ihe Contractors License Wws.). ❑ I am exempt under sec. Business antl Protessions Code lor this reason: Signature: Date: Ownar ID verlfied by dAvers licensa. ❑ Yes ❑ No Dnver's License No. Venficetlon ol Ownership by (type of document, i.e. - proparty tax bill or Aeetl): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: Expires: ❑ I hereby certify Ihat no excevetion five (5) or more feet in dapth into which a person is required to tleScenQ wlll be made in connection with wark euthorizetl by this pertnil, end that no building structure, scattolding, felsework, or demolition or Olsmantling thereol, will be more Ihan thirty-six (36) feet high. (Chap. 32, Grp 2, An 2, Sec. 3a7, Title 8, Califomla Atlministretive Code). ❑ As owner-builder, I will not employ enyona to do work which would require e pertnit from Ihe Division of Indusinal Satery, es noted above, unless such person has e pe�mit to tlo such work Irom ihe tlivision. Signature: Date: Division af Intlusinal Sefary Pertnit Number: CERTIFlCATE OF COMPLIANCE AND AIJTHORRAl10N OF ENTHV: I certiy under penelry ot perjury that I have read this application and state thet the intormetion given is correct. I agree to comply wlih all staie laws end ciry ordinances releting to bulltling construction, end euthorize representatives ot the City of Coste Mesa to enter upon the ebove�described property for inspection purposes. I egree not to occuDY or ellow occupancy of any huilding euthorized by this permit until final inspection. ��/.. • �- : s/i_� � i � .�.r. COUE �• INSVECTIONTYPE 1616 Fixed System Flnal Fire Prevention 1266 Pool Spe Finel 200 Finel Re-Rooi 201 FIneI8locWReteining Wall 202 Finel Faciory Fire Place 203 Flnel Sign 204 Final Demoli�ion Jj�¢ ��j S,QQf� INSPECTIONTYPE 206 Final Mechanical 208 Final Plumbing 210 Final Electdcal 212 Final Fire Preventlon 220 Final Planning Approval 222 Final Site 250 Final Building/Occupancy ceg u�s 9-ii-oi /s 1� ` ' � ' ! • � , � o July 16, 2001 LAMDA ENGINEERING AND DEVELOPMENT CNILSTRUCTURAL-QEOTECHNICQL-FOUNDQ710NS-T24 LAND SURVEYING AND DEVELOPMENT CONSULTANTS 32310 CORTE 7J\MORA TEMECULA, CA 92592 909-676-7688, 909�76-7288 fax Email: lAMOADEV�EARTHLINK.NET JOB No.: 0701 sfd 531 ULTIMO CONSTRUCTION 1411 E. Borchard Ave. 1�0 �'—D �� Santa Ana, CA 92705 Review of structure and recommendations for remedial repair for MCMILLAN Residence located at 77l HUDSON AVE. Costa Mesa, CA INTRODUC'f10N In accordance with your request, we have completed the subject report, the scope of which is iimited ro the following: 1. Reconnaissance of the site. - 2. Review of level survey by IJLTIMO Constrvction and Engineering. 3. Review of remedial plan by ULTIMO ConsWction and Engineering 4. Preparation of this repoR. SITE CONDIT►ONS The existing building is a one story wood 6amed covered with stucco,one stoty residence built approximately in 1970's, approximate area is 2000 s£ There are various signs of cracking of the stucco outside the residence, the outside concxete slab work also shows signs of cracking and separation. There are signs of obvious settlement of the building in the area facing the back yard, the Level Survey prepared by ULTtMO indicates difference in elevation up ro 2 inches near the rear of the house. CONCLUSIONS Based on the information obtained in this limited review, it is our opinion that at the time of the inspedion the sdtl�na�t of the building can be charaderized as minor, said settlemen4s could have bcen caused by a combination of soft soils and water saturation. 7'he rate of settlement and or distress shown will most likely continue at about the same rate as it has in the past, however, over saturation of the soils in these areas may incrwse the rate of movement. RECOMMENDATIONS The fo!lowing recommendations are given to help mitigate the existirtg Problems cxused by the soil conditions on site. 1. UNDER PINING In-order to support the house foundation, galvanized steel piers should be Driven to the solid material. These piers should be anchored to the footings the depth is eacpected to be 25 to 35 Feet. See DET 1 on SNC 1 of the plans prepared by 1JLTIMO Construction. The location of grout injection points and underpinning resistance piles is shown on SHT 1 of the plans Prepared by ULTIMO Construdion, A!! the remmmrnda[ions ort report no. 994 i by SBCCI are hereby made part of this report. Furthermore all notes as stated on the plans prepared by Ultimo Construction are to be followed and are made part of this report. 2. DRAINAGE Drainage around the b�ilding is vay important, and should be field verified by a the contractor. Minor adjustment may be required to be determined on the field. 3. MONITOTING Once the repairs are completed a manometer survey shoald be completed. Ifdistress is noted in the future another mananeter survey can be perfortned to see if any movement has occurred. a� Page 2 MCMILLAN FILE:SFD531 4. EXTERIOR STUCCO It is expected that some normal cracking in Ihe stucco may occur in the future. Covering some of these at areas with wood or metal siding would help hide minor movemenu. 5. INTERIOR If some cracking does occur in the inteaior walls, the use of heavy wallpaper, and paneling can help hide nuisance cracks. Paneling can hide the largest cracks and wallpaper the smallest. If any wall cracks are to be repaired with bedding caompound, tape and frnishing compoured just like a wall joint. 6. CONCRETE If any lazge areas of conaete are to be placed or replaced on site the soil should be checked and cleaned from any deleterious material and the top 12 inches removed and re-placed using manual compadion as neoe,csary. The conaete should also be at least 5 inches thidc and reinforced with N4 rebar on 18" oenters each way. Large concrete slabs should have crack control joints at 10-foot c�t�s and small ones should have them a 5-foot centers. The edges of slabs should be doweled into the adjacent concrete to reduce ditTerential settlement. Also, any cracks or separation in the concrete should be kept sealed with an elastic sealant to prevent surface weter from saturating the soils b�eath the concrete. LIMITATION$ The recommendations contained in this report are based on the 6eld observations and data obtained from this limited review and our present frnowledge of the house construdion, it did not include subsurCace exploration, field and laboratory testing, and analysis by an engineeri�g geologist and or geotechnical engineer, no fumiture, carpets or other items were moved duririg aw review, except as noted in the report. It is possible that variations could exist be[we� the observed conditions and those found during construc[ion, lf any conditions are encountered at the time of construdion that are different to those described in this report, our firm should be noti6ed immediately in order that a review may be made and any supplementary recommendation provided. Our firm has prepared this report in accordance with the scope of services and makes no other warranties, either expressed or implied, as to the profccsional advice provided under the tertns of this agreemmt and described in this report. Ifyou should have any questions regazding this repart please feel free to contact us at your convenience. Rcsoectfiillv submitte�l_ OWNER O�BEIRN, G. H.� JOB ADDRESS']'j1, HUdsOTI Av2. 3�2 BUILDING PERMIT NO. GENERAL CONTRACTOR p�er-Builder VALUE $ 6(O,pp AP No. nnna LOT 1�� TRACT �Kpp FIR� 7,ONE DESCRIPTION OP WORK eA� a�+. c.,,. � INSPECTIONS coat OCCUPANCY DATE � GROUP r TYP� �i 7,ONE SUBCON'PRACl'OR �'� 16862 COSTA MESA BUILDING-SAFETY DEPARTMENT P. O. BOX S77 COBTA MEBA. CALIFOi2N1A For Applicanf fo Fill In Complefely TYPE OR PRINT BUILDING ADDRESS (J OG � ✓ � COSTA MESA. CALIFORNIA Il ri_ m�ri- �-- � MAIL � STATE TEL. - � NO. TEL. NO. n�dner � v i.. _� I NO. OF BLD08. ■ 86TBACN LINE FROM DESCRIPTION OF WORK iz'Xxo' ROOMS WALLJ�_ _ �ftOOF FEE RECEIVED APR 3 i96,� APPLICATION F �1��DSTOAe MESA BUILDING For Office Use Only BUI COSTA MESA. FIRE ag�iN� � Z 1(' /' I PLANB Y I BUIL� NG EW A �ecw� � . 1. .. . � c ICENTHP LIN2 6T.) E � ' _ � �/ � � HEREBV ACKNOWL6D�H THAT i HAVE READ THIB APPLIGTION TNE AMOUNT SXOWN UNOER VALUATION 19 FOR THE AND BTATE THAT T OVE IS GORRECT �ND AGREE TO GOM- pURP08E OF E6TABLIBHING A PERM�T FEE ONLY. PLY WITH ALL CI ORD ANCES AND �ATQ uW6 pEQUUTINO Bu1LDINa CONB uCl'lo . � ` VALUATION , J SIGNATURE OF PERMIT FEE $ �� PERMITTE ' / ,�f� n / a $ /�D / PLAN CHEGK $ AUTHORIZED AGENT w� o TOTAL FEE LL -Lot 14 T . � - � 1��'73 COSTA MESA BUILDING•SAFETY.DEPARTMENT P. O. BOX 9f7 COBTA MHBA. CALIRORNIA For Applieanf to Fill In Complefely TYPE OR PRINT COSTA MESA. CALIFORNIA I � NO. OF BLAGB. NOW ON lOT O USE OF EXISTING HLD NONE 6ETBAGK LINB FROM C¢NTER OP 8lA¢8T REAR YARD r /� l j SIDE YARD ILLFT ti RIGHT DESCRIPTION OF WORK NG 'EXTERIOR WALL I ROOF W....d 9YLj� COVERING STI1Cf.0 COVERYNt" � USE OF BU7LDING AN� WORK TO BE PERFORMED F�E RECEIVED �IAY 171969 FINANCE DEPT:� APPLICATION FORy P��t�TA MESA ' BUILDING Fo� Office Use Only BV COSTA MESA, CALIFORNIA APPROVED ZONING LONE NO.OF U6E OF ��l I PLANSII BUILD�� .L C. LEGAL T.. DEBCHIPTION TA�i I.�� 11B A. P. No. none YARDS EVES APPROVEO ALLOWI (CENTHR LINE 9TJ _�, rlb , at Y a�� • I HEp¢BY ACKN�W�DGE THAT 1 HAV6 RBAD THIB APPLIWTION TH8 AMOUM BXOWN UNOER VALUATION IB POR TH¢ AND eTAT2 THAT THH ABOVE IB GORN6GT AND AGREE TO COM- PUHP08E OF E8TA9LI8HING A PENMIT FEE ONLY. PLY WITH ALL G�TY OftDINANLEe ANO 8TAT6 L�WB REGULATIN6 euuolNa CONe ucnoN. VALUATION eq/� SIGNATURE OF ✓ PERMIT FEE $ �OL � PERMIT�B $ � ` PLAN CHEGK $ � �" AUTHORIZED AGENT I�/ �� TOTAL FEE G