HomeMy WebLinkAbout570 JOANN ST - Building Permits✓� a
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(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.�a,4�LDING PERMIT n FAIR DRIVE, COSTA MESA, CA 92626
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JobAddress: 570 JOANN ST
Suite:
Vicinity: 4-UNIT APARTMENT BUILDING
Parcel Number: .42216306,
Zoning:
ApplicanC CHI, CHONG
Address: 831 S GRANDVIEW ST �"
SUITE 302 . . � Phone: (213) 383-6995
LOS ANGELES, CA' � . � Zip: 90057
ownec MICHAEL R. YOUNG
Address PO BOX 1475
COSTA MESA, CA
Contractor: AIDOS ROOFING
Address: 831 S GRANDVIEW ST
SUITE 302
LOS ANGELES, CA
Zip: 90057
Arch :
Address:
Phone:
Phone: 774/806-7132
Zip: 92628-7475
Phone: (213) 383-6995
� License: 765538
_ Eng:
� . Address:�
ISSUED BY:
Status: ISSUED
Applied: 72/10/2001
Issued: 12I10/2001
Phone:
Zip: License: License:
_ SCOPE OF PERMIT _
� REROOF EXISTING 2-STORY, 4-UNIT APARTMENT BUILDING (17 SQ). TEAR OFF EXISTING COMPOSITION SHINGLES
8 INSTALL NEW 4-PLY WITH CAPSHEET. BUILT-UP ROOF SYSTEM.
Plan Check:
Permit:
SMIP Res:
SMIP Com:
Other:
Inspection:
Total
$0.00
$69.25
$0.50
$0.00
$0.00
$0.00
$69.75,,
SETBACKS
MAIN STRUCTURE Front 0• 0
ACCESSORY Front 0-0
PARKING Existinq: o
NOTES:
Rear 0- 0
Rear 0- 0
Re uired: 0
FEE SUMMARY
Calc Valuation: sz,000.00
Claim Valuation: S2,000.00
PLANNING & ZONING
LeN 0. 0
Lefl 0- 0
Proposed: 0
Right 0-0
Right 0- 0 � �
NO710E: The work authorized by this permit shall comply with all applicable handicap access requiremenis under Calitomia 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 1B0 days, or if work is suspended or abandoned
for a period of 180 days. '
INSPECTIONS: In order tor the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
requlred Inspectlona and flnel approval must be obtained. Failure to obtain inspections and final approval will result in the axpiration ot this permit.
FOR INSPECTIONS CALL: (714) 754-5626
zaauae �u�oo�
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WORKERS' COMPENSATION DECLARATION:
I hereby allirm under penelry ot perjury one of the following declarations:
❑ I heve entl will maintain e certitiwte ol consent to selbinsure br workers' compensetlon, es provitlea tor by section 3700 of ihe Labor Code, for t�e peAormence of ihe
work tor whiCh ihis Oertnit is 155uad.
j� I have end will meintain workers' compensa6on insurance, es requiretl 6y sectlon 3700 ot Ne LahOr Cotle, tor ihe perto�ance of the work for whiU Ihis pertnit I5 issuetl.
My workers' compensation Insuran^ce wrner and policy number are: ��. OD D r��O
Carner: ��� �(r�iJl/ PolicyNumber: L
(lh/s section need not De canpleted i! Ne permif is valued et one hundred dollars ($100J oi lessJ
❑ I cartity that in tha perfortnance of Ihe work for which this permit is issuetl, I shell not employ eny person in eny manner so as to become subject to Ihe workers'
compensation lews of Calllornia, e{�tl egree that if I shoultl becoma subject to t�e workers' compensation provisions of Saction 700 of the Labor Cotle, I shall torthwith
comply with Ihese provisior7,5. / ��
�'>I �
Applicant Slgnature: �� 1n � �"Date:
WARNINQ: FAILURE TO SECURE'AORI(ERS' COMPE ATIO OVERAGE IS UNLAWFUL AND SHALL SUflIECT AN EMPLOVER TO CRIMINAL ENALTIES AND IVIL FINES UP TOONE HUN�RED
THOUSANDDOILARE($100,000),INA�DITIONTOTHE�7STOFCOMPENSATION,DAhNGE$ASPROVIDEDFORINSECTION3]WOFTNEL4B �RCODE,IfJrEREST,ANDATTORNEV'SFEES.
LICENSED CONTRACTORS DECLARA710N:
I hereby ettirm Ihet I em licensed n er mvisions of Chapter 9(commencing with Section 7000) of Division 3 of ihe Business and Professio e, end my license is in full
force and aMecL Lic.» � Class k '�J �� C'
ConlrectoYs SlgnaWre:� e � � �Date: . � •2 ,� � �—
! /� i 1
f
CONSTRUCTION LENDING AGENCY: �
❑ I hareby eMirtn Ihat there is e consimction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Cotle).
Lentler'sName: ______ LendersAtldress:
Signature:
OWNER•BUILDER DECLARATONS:
oate:
I hereby eMirtn thet under penalry of perjury ihat I am EXEMPT FROM 7HE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Businass entl Professlons
Code: Any ciry or counry which requires e permit to consWcL alter, improve, tlemolish, or repair any structura, pnor to its issuance, elso requires the epplicant tor such permit
to file e signetl statement that he or she Is Iicensed pursuant b the prodsions of the Conirectors License Law (Ghapter 9(commenUn9 with Sectlon 7000) of Division 3 oi the
Bu5in855 entl Professlon5 Code) or Ihat he or she is exempt therefrom end Ihe besis tor t�e elleged exemption. Any violation of Section 7031.5 by any epplicent lor a permit
subjecis tha applicant to a civil penalry oi not more ihan five huntlratl tlollers ($500).�:
❑ I, as owner of Ihe property, or my employees with wages es I�eir sole compensation, WILL DO THE WORK, antl the strucWre Is not intendetl or oHered for sale (Sec.
7044, Business and Professions Code: The Coniractors License Lew does noi apply to an owner of properry who bu�lds or improves thereon, end who tloes such work
himsell or hersetl or Ihmugh his or her own employees, provided ihet such improvemenis are not intentletl or ottered for sale. It, however, ihe building or improvemenl is
soltl within one year ot completion, Ihe owner-builtler will heve the burden of proving ihat he or she did not build or improve for purpose of seleJ.
� I, as owner ol lhe property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business entl Prolesslons
Cotle: The contrectors Llcense Ww tloes not appry to an owner ol property who builtls or Improves thereon, and who contracts tor such project wlth a contractor(s)
license pursuant to the Contrectors License Laws.).
❑ I am exempl under sec.
Signatura�.
Owner ID verified by driver's license. ❑ Ves ❑ No
Business and Professions Code for this reason:
Verification ot Ownership by (type of tlocument, i.e. - property tex bill ar deed):
Driver's License No.
Date:
Expires:
DIVISION OF INDUSTRIAL SAFE7Y PERMIT CERTIFICATION:
❑ I hereby certity thet no axcavation five (5) or more feet in depth into which e person Is required to tlescend, will ba matle in connection wlth work autharizetl by Ihis
pertnit, entl Ihat no building sWCWre, scaHolding, falsework, or tlemolition or dismantling thereof, will be more ihan �hirry-six (36) feet hig�. (C�ap. 3.2, Grp 2, An 2, Sec.
341, 71t1e B, Califomia Atlministretive Cotle).
❑ As owner-builder, I will not employ anyone to tlo work which would require e pertnit trom the Division ot IndusMel Satery, es notetl above, unless such person has e
permit to tlo such work from t�e division.
Signature: Date:
Division ot Industnal Satery Parmit Number:
'_-
CERTIFICA7E OF COMPLIANCE AND AU7HORIZATON OF EMAV: I certify under penalty of perjury that I have read ihis epplication end slate thel tha information given is
correct I agree Io comply with all s;ate lews and ciry ordinences relating to building construction, end aulhorize representatives oi the Ciry of Coste Mesa to emer upon the
ebove-descnbed property for inspection purposes. I egree not to occupy or allow ocapancy of eny building authorized by �his permit un�il tinel inspection.
cooe �.
1616
1268
200
201
202
203
INSPE� _--= �
Fiaed System Final Fire Prevention
Pool Spa Final
Finel Re-Roof
Finel Block/Retelning Wall
Finel Fectory Fire Place
Finel Sign
204 Final Demolitlon
QAff. II�L9
'� (IG�/1�
COOE 1 INSPECTION TYPE
206 Final Mechanical
208 Final Plumbing
210 Final Electriwl
212 Final Fire Prevention
220
222
250
Final Planning Approval
Final Site
Finel Building/Occupancy
p7.V�Iiiitll.l4'7
N
�
Applicant �o fill in all s0aces exceDt Ihose within heavy borCer Ilnes anE sign all appropriate Oeclaralions.
CITY OF COSTA MrElSA C NSTRUCTION PERMIT PERMIT NO. TRACT NO. LOT NO. � 11NIT Nfi
Project Address s I� ����'�N' <r r '
�'�ipplicanYs Mailing Addressi%i ��2-�y�/ � G - C "
�Owner's Name C ��,'� �/�v�J ✓ ���� Phon �
i'Address/7�iQ"/Y�,(`iC%i�il � �f7/����/ �,.
ArchlEn9. I�cax�t#y c1�270�
Address (mailingY�/��G�"' L�J��'��1 (1 � �L ' �//l//�"'/►Id�
City License Na. Dyll2p %�
LICENSED GONTRACTOR DECLARATION
1 M1¢reby atti�m that I am li<ensetl untle� provi5ion5 of Charte� 9(commencing
with section 7000) of Division 3 of the Business antl Professions Cotle, antl
my license is in full for e ntl effect.
License Class Licen o.
�ate `f� l�— �r 5'9 t � C '/�� j,�'_��
WORKERS' COMPENSATION DE RATION (/
� nereby atfirm tnat I have a certificate of consent to self-insure or a certificate
� W�oj�k-?ers' Compensation Insurance, o� a certifietl <opy thereof (Sec/tlon
po�cyK16�,C,����� Company �U�r ///C/
Certifietl copy is hereby furnishetl.
r fietl copy is fil¢tl with the city B' ing ' isio
�ate ��u�__,_.� �—Applicant
EXEMPTION FROM WORKERS' COM NSATION ECLARATION
(This section neetl not be completetl if t e permit is for one huntlretl ($100) o�
less).
I cer[ify tnat in the perPo�mance of the wo�k tor which this perm�t is issued, I
shail not employ any person in any manner 50 as to become subject to the
Workers' Compensation Laws of CalitOmia.
�ate Signature
NOTICE: Ii, after makin9 this tleclaration, you shoulG become subject to the
Workers' Compensatlon provisions of tM1e Labor Cotle, you mus[ forthwith
comply with such provisions o� this permit Shall be tleemetl revoketl.
CONSTRUCTION LENDING AGENCV
1 nereby affirm that ffiere is a wnstruction Iendin9 agency for the performance
of the work for �which thi5 permit is issuetl (Section 309� Civ. CJ
Lentler's Name ��
Lentler's Atltlress
OWNER BUIL�ER bECLARATI N
' I hereby affirm that I'am exempt trom the Contractor's License Law tor the
followin9 reason (Sedtion 7031.5 Business antl Professional Cotle: Any city or
county wnich requires a permit to con5truct, alte�, improve, tlemolish o� �eDair
any sttuc[ure, p�ior [o its issuance, also �equires Ihe applicant tor sucn permit
to ti�e a 5ignetl statement that he/she is licensetl pu�suant to the 0/ovi5ion5 of
the Contvactor'S License Law (CM1apter 9(commencing with Section ]000) oi
Division 3 of Ihe Busine55 antl Prote55ions Cotle) or that he/she i5 exempt
-herefrom antl the basis for [M1e allegetl exemplion. Any violation of Section
]31.5 by any applicant tor a permit subjects the aOP�icant to a Civil
enalty of not more tM1an five M1untlretl tlollars (g500).
❑ I, a5 owner of the property or my employees with wages as their sole
comp¢nsation, will tlo fhe work, antl the structure is not intentletl o� offer¢tl
for sale (Section ]044, Buiiness antl Pwfessional Cotle: The Contracto�'S
License law tloes not apply to an owner of a property who builtls or improves
thereon, antl who does such work nimself/nerseli or tnrough his or her own
employees, providetl that such Improvements are not intentletl o� offeretl for
sale. If, however, the builtlinq or improvement is soltl witM1in one year of com-
pletion, the owner will have the burtlen oi proving he/she tlitl not builtl or im-
p�ove for the purpose of sale).
❑ I, as owne� of Ihe property, am exclusively contracting with IicenSetl con-
Vactors to canstruct the project (Section ]044, Business antl Professions Cotle:
The Contractor's License Law tloes mt apply to an owner of property who
builtls or improves [M1ereon, antl who cont�acts for such projec[S with a con-
t�aclo�(5) license pu�SUant to the Cont�actor'S License Law). I am aware tha[
proof of their Worker's Compensation insurance Shoultl be ProviOetl [o me.
❑ I am ezempt unCer Section B. & P. C. for this r¢ason
Date
I hereby certi
intormation is
antl state laws
sentatives oi
inspection pur�
Siqnature _�
, Drivers' Licen
AF 0865-4 , rev.
Owner _
have reatl th
the above
ortlinances
TVPE Of CONSTRUC710N
❑ CONVERSION ❑ I
nDESCRIPT�
/
ADD
TVPEOFPERMIT GRADING LJFOUNDATION 'E.�STRUCTURAL
❑ TENANT ❑ E��_y/�� RICA� PLUyA¢ING ❑ MECHANICAL
� ❑ OTHER '/ \
PROJEC7 DESCRI TIP ON'
CON STRUCTION TYPE
ZONE
Remarks: ��
� L�.
Bar Sink
Backf w Preventer
Backf ow Irrigation
5Q.
t/ N VALUATION$�
_ GRA�INGCU.VDS. AC
L�`�L"�� P.F�i 9�
rinking Fountains
loor Drains
loor Sinks
35SCNIC2 OIILICLS
Kitchen Sink
Lavatories
P—Trap
Roof Drains
Reinspection Fee
PLUMBING
Service Sink
Sewer Cap
Sewer Connection
Solar CollectOrs
Solar Piping
Solar T
S ' ming Pool w/Spa
Urinal
Water Closet
Water Heater
Water Service
Auto-Wash
Laundry Treys
$15 Issue Fee
MECHANICAL
Boiler
Duct - Under Ground
Duct - Structurel
Duct - Ventilating
EzhaustSystem ❑ Multiple❑
Firepl/Fact.6lt. ICBO #
Heating System & Ducting
❑0�100,000 BTU 0700,000�
' Oate�l=vJ rj � I
e or 55 � - ' Reinspection Fee $15
10/84 White - Builtling; Canary - Applicant; Pink - Accounting; GolEenwtl - Assessor
Hoad or Type I ❑
Canopy Type I I ❑
Refrigeration
]o-ioo,o elaTu ❑ioo,000
lys n Repair/Alteration
F ire Dampeis
Registers
Issue Fee
IR
_,� A.P.#
JN
S Main Buildin9:
— E
T Front
A Rear
� G Right
_ g lef[
— Ping. Ref. #
,G Planning Notes:
FEES
_ Zone
Accessory Building:
2
� O
N
I
N
G
R
Parking Fieq./Provided E
Q
M
T
S
ELECTRICAL
Automatic Washer Transformer ❑ 15�50 KW
Construction PoleSub. � 50+ KW
Cooking Unit
Dishwasher -
Dryers ❑Gas ❑Electric
Fan
F.A.U.
Fixtures
Device Boxes
Outlets
Switches
Garbage �isposal �
Generator �0-5 KW OS-15 KW
Metet ❑up to 100amps
Meter ❑over 100amps
Sub Panel .
Motors�0-1 HP �1'/: - 8
In olar �9-15 HP �16-15+
Pole Light
Range
Sign
Standing Sections
Trash Compacmr
FEES
e
$ 3
Rainspection Fee $15 'Issue Fee $ 3
FEES
DEVELOPMENTSERVICESREQUIREMENTS:
Zoning Approved By Date
Building Approved By Date
Application Issued By `T • Dat
� SUM ARV OF FEES � �
BUILDING PERMIT $ �— SMIP . $ �
PLAN CHECK $ PERMIT
PLUMBING $ ISSUANCE $
PLAN CHECK 25% $ ENERGV P.C. S
ELECTRICAL $ GRADING $
PLAN CHECK 50% $ MICROFILM $
MECHANICAL $ TOTAL FEE $�
$ 3 PLAN CHECK 25% $
❑�a�u9s-aooau�v - -
: nvn�ieu �*xc. <',:ne ' -
CONSTRUCTION AND PLANNING . POOL & SPA
APPROVALS �rPermit# Date Inspector p�ppROVALS Permit# Qate Inspector
• �,'�
1� Temporary Ele�cfrical'Service or Pole 52. Pool & Equipment Location
i�
2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement
3. Electrical Conduit Utility-Undrgmd. 54. Forms
4. Electrical Conduit-Undrgmd. 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 - f 59. Gas Pipe, O Undrgrnd., Test
9. Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap, O Undrgrnd.
70. Structural Floor System � 61. APPROVAL TO DECK
17. Property Sewer Line & House Connection 62. Backwash & Receptor-Final
72. 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 � � j
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT "� ��
A
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.StorageTank OGas ❑Oil ., �
25. Roof Sheathing.' , 74. Overhead Hydro •� '
26. T-Bar Ceiling (Structural) & Monocoat ,�75. Dry Chemical ,� �
27. Frame and Flashing � 76. Dry Standpipe ' � . � ' ! �_ � �
i � ; ':
28. Lathirig & Siding � 77. FIXED SYSTEM FINAL • ��
29. Insulation i 78. FIRE PREV. FINAL ., �
30. Drywall Nailing HEALTH DEPT. REQUIREMEIVT �
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 " �
�e�
35. Final Gas Pipe-Test � , � �� � `
36.�Hood or Canopy . , ;' • '� �y' �'
- l� /,
37:, Final Factory Fireplace �` �` �-�'
.�J �; .-.,
38. Final Plumbing i % -� A; '� '
i_ . �i�,�'I��-
39. Water Service-Final `%,+ (�'�.�,, '-� % �'�', ' V
j� •
40. GasService-Final �� ;' �� � � �-
�'41. Solar pomestioFinal �(% �„ ,�! �':! ; �; i';1 ��;
,42. Backflow Preventer /�' ' � ' q � "
�i . � � -.
;43.,Backflow Irrigation '�"� j� �� � �'`%, � =
_ ,
��.�' � '
'-44•. � Landscape Irripation System � �_ ,_ �� % ./ � -
.1. 'i
'45_�Sound Attenuation '' � �' ' � , .- `✓ '
r' i �
48. Handicap Regulations v� ;�, / - , �
. i t :� •
47.=FINALSTRUCTURE&BUILDING "` � '' r; �'� ; %' ' '
�� ,'
48: Special Requirements Completed "'� n� !!�•, -' �� C' �, � �. '
49. Electrie Release to Edison � � ' ,i ' �
.
50. Gas Release to Southern California Gas Co ��:; �� . (�
51. CERTIFICATE OF OCCUPANCY
-r `__ i'
No. Date _ J„_
� �
OWNER
JOB ADI
�GyENERP
ph_. eC'
soi�
WS
W aiER
ROUGN PL
LINE � J HOUSE CON.
SYSTEM
FOUGH HE>T�NG AND
UNOERGROUNO '�—I POWER
ROUGM WIRING � ,
FRAME PNO FLASHING�/��(J—/
LATHING — IN �) OUT �
PV°iER. BROWN COFT
5" 'UP4L. FINAL
HE.. �NG, VENT., FEFRIG. ANO �.0
PLUMBING. FINAL ANO G�5 TEST
FINAI
niui nmr. vivel
T
DATE
SUBCONTRACTOR
S�
r{
�n ���:a�
::,-�,.,...
COSTAMESABUILDING-SAFETVDEPARTMENT fi19� 3/1,9_/�79�.:•. . 96r46 TL'�
P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 �� � - "�' - �` � � �"
AP I AT ON FOR STRUCTURAL PERMIT
For Applicant [o Fill in Comple[ely — Use Ink Only RE D DATE RECEIVED D TE UED
ADIDRES$ S7� J U LQ
OWNER � �L /��^ .L�/�(J
A.P. NO. /'3�O 6 PERMIT NO.
MAIL UILDING
ADDRESS I�� H'�S ADORESS y%Q �0'� w� S, C/�/� . ._
n ' e� �+T 3
CITY �S�.y e n NpL ()SQ,JQ POKT�i`qqCT� ytVl / iiG/M BLOCK
CONSTRUCTION W A P
LEN�ER 1.� � V, �/
BRANCH —
OWNER ��L�t /�t eN✓
ADDRESS � //1� n /�)
ARCHITECT TEL. S �fQ�OQ `�RD�L� (/ (/
OR ENGINEER '��
FIRE
AODRESS � 20NE T PE GROUP
APPROVED �
CONTRACTOR � �. p2 BV DAT '�
ADDRESS p� q�...� v
TEL. ZONE NO.OF USE OF NEW � 1L—
CI7V �S � �G n NO•Sy(.'��S-O �� BUILDIN �
F STATE CITV �'ARDSAPPROVED VAROSAP ROVED
LIC. NO. � LIC. NO. MAIN BUILDI G AC SSORV BUILDING
(FROMGLSTR )
(y 512E � G K(Op NO.OF BLDGS / /
�. OF LOT NOW ON LOT ROM FT.
d USE OF f �(
^ EXISTING BLDG. L� L`�� � TS T FT
ln I Ii
� Separate permits are required for �. si E Q FT Fr.
� electric, plumbing and heating work. �EAR i n OS - O`
� F FT.
W USE OF BUILDING AND WORK YO BE PERFORMED
F DISTANCE BET. BET. MAIN &
QMAIN BLDCS. ACCESS BLDGS.
'� A� O�QT /d , l /V � C VRP.ys APPROVE�� '
Q
� r ,;,... ,�t , • �;,, � �r �Ro
� � aScu <i✓b 7 x
a
W
Q I hereby acknowletlpe Mat I have reatl this application antl state �
N
a ihat the eCova informetlon is eorlact entl apree to eomply with m
� all lowe rep�Intinp bulldinp eonstt�ction, ond I shall not amploy
i
Z eny perwn In viOlatlOn Of tha wO�kman's compensation lews o1 m
� ma s.eca o, ceuro.�ie. I'IO FOR SPECIAL REpUIRET;^;'7: m
�r I heroby cartity thot I am properly Iicansetl as a eonttecior unGor SQ. FT. w
tha Smm of Callfarnio Bue(nnsa and Profeuions Cotle, Dlvision 3, HE AMOUNT SHOWN UNDER VALUATION IS FOR m
Cheptor 9, entl that sueh litensas ere in full forca antl eftact, or I TME PURPp6E OF ESTABLISHING A PERMR FEE ONLV: � �
em axampt from the provlslons ot Ne State of Ceiifornia Business VALUATION p �
antl Professlons Cod , Divielon 3, C�eptar 9. PERMIT FEE E � � m (�
�� � PLAN CHECK $ � 8'(� o V\
Slgnotura of / /�D u M
Pofmitten $ � TAX E � �
U �Aut�orizod ABent TOTAL PAID S