HomeMy WebLinkAbout678 JOANN ST - Building PermitsPflOJECTR00HE5S: ('78 JOANN JrT
OWNEfl'SNAME: LITTLE JIMMY M �
aooness: 2 q q g W f NDWARD L N
NEWPORT BEACH, CA 92620
uwir: A 6 B
548-8475
AHCNIENGINEEN: NEC.NO.:
}l ADOHE55: UNIT:
i
PEflMITTEE: JIMMY M LITTLE ( 714 ) 598-8475
� aooeess: zqqg WINDWARD LN
NEWPOAT BEACH CA 92660
LICENSED CONTPACTOB OECLABATION: I hereUy aflirm ��a� I am lic¢nSeA untler provisions o� Chapter 9lcommencinA wii� Sedion
7000� ol Orvlson 3 ul �he Business and Pmlessions Coao, antl my license is in lull Porce antl effec�.
CITY LIC.: STATE LIC.: CUISS: EXP ;
Oare: Signature:
WOBKEflS' COMPENSATION OECUINATION: I here0y a�lirm I�a� I have a cerlificate of consen� �o selFinsure or a cehilica�e of Workers'
ComOensation Insurance. or a cenifieA coDY �hereof (SecUon 3800. Lah. q.
POLICY NO.: E%P. DATE:
COMPFNY:
. � CerlifieA coDY is hereby �umis�ed. ❑ Cetli�ieG Copy iS ��IeJ wiih ��e tity BuilGinp OiviSion.
�
/
��
I
Dale: Appbpant:
EXEMPTION FBUM WOHKENS' COMPENSRTION OEQAMTION: (iNs sttti0n ntttl n0� Ge comD��� ii Ne perm� is �a one �unEr[d (5100� or lea�.
I ceNly Ihat in I�e Oe�ormante ol Ihe work br whic� Ni5 permit i `ued. I SAall not emDlOy any person in any mannu 5o a5 ia heCome
su�jecl lo I�e WorkeQrs' ComDen �ion Laws ol Calilornia. �
Date:, Z �� V � �� SiAnature: �
NOiICE: II. alter makinp ihis Aeclaration, yau shaula Uecome suble�� �o tne wurkers' Compensation prmisions ot tne LaGor
CoEe. you must forl�wiih comply wi�h SucA O�ovisions or �his permit shall �e 4eeme0 revake0.
CONSTBUCTION LENOINC PGENCY: 1 hereby allirm Ilui t�ere is a conSVuclion IenEing agency Por �he pe�ormance of lhe work lor
wnic� ��is permit is i=.sued �Section �097. Civ. C�.
LENOEfl:
AUOflESS:
OwNEP BUILOEB DECLABATION: I hereby affirm inat I am eKempt irom Ihe Coniractors' State License Law for tha tollowinp reason
(Seciion 703L5 Business ana Pmlessional Cotle: Any ciiy ol couNy which repuires a Oermi� to constmci, al�er, improve, tlemolish, or
repair any stmpure. prior �a its issuance, also requires I�e applicanl lor suc� permil Io file a signetl 5[atement Ihat �GShe is licensed
pursuanl lo Ihe pmvisions ol ihe Coniracmrs' State License Law (Chapter 9(commencinB wiN Sec�ion 7000) of �ivision 3 ot ��e 9usine55
antl PrO�ession5 Cotle) ar I�al �e/she is exempl I�erelrom and t�e basis �or Ihe alleAeO exemption. Any violaiion ol S¢Ciion 7031.5 by
any applicanl for a Dermit subletls Itle aD0licanl lo a civil penalty 0� not more Ihan five huntlretl Dollars (5500).
I, as owner ot �he pmpeny ar my employees wit� wages as iheir so�e compensa�ion, will tla �he work, an0 tAe
❑ simcmre is not inteneetl or oflered lor sale 15ection 70aa, Business anE Pmiessional CoOe: T�e Contracmrs' State License Law
aoes nol apDly �o an owner ol a properiy who hui105 or impmves thereon, and who Ooes suc� work hims¢Itlhersel� or Nmuph
�is or �er own employees. pmvideU I�al such impmvemen�s are noi intenaeJ or ofleretl �a� sale. I�, however Ihe Guildinp or
impmvemeni is sold wM1hin one year ol completion, Ihe owner will have ��e hurden oi Droving he/she tlitl no� Guiltl ar impmve
lor the Durpose ol salel.
I. as owner oi the pmpeny, am exclusiveiy coniracting wi1� licensed conVac�ors to conslmci Ihe Dmjeci (Seclion 70Gd, Business
� antl PmfeSswns Code: T�e Contractors' State License Law Oces nol aD�N �� an owner ot O�opeM who builtls or imD�aves I�ereon
antl who coniratls lor su[0 Dmlecls vnlh a cOntratror(s) li[ense Dursuan� to t�e Contractors' StatC Licen52 Law�. I am aware
Ihai proul ol t�eir Warker'S Compensa�ion in5urant¢ S�oula Ge pronae0 la me.
� I am ex¢mp� un0er Section: B. 8 P. C.
�or ihis reason: � 4 �
oaie: ` ✓— "' � ^ ` �_ Owner "�/� a
i do nereby cenily that I am aware ai ane untlerstand the requiremen�s ol Calilornia HeaIN an0 Safery Code Sections 25505, 25533, anC
2553d and thal I or any lulure builtling occu0ani wilVwill no� ([ircle one) neetl �o comON Y^�h saie state coGes an0 t�e rEduir¢menis for a
permil lor conslmclion or moditicalion �mm Ihe Air Oualiiy Management Ois�ricl. Fesitlential conslmdion applica�ions are exempt Imm
i these Omvisians.
Date'. ApDlicanc
I �ere0y cetlily Iha� I have reatl Ihis aDPlicaiion and slale Ihal �he above in�ormalion is correc� I apree to comply wilh all ciiy and county
ordinances and slatelaws relaiing�o buil0ing ionslmclion �ereby aulhoRe repre5entatives o���is cityto en�er uponthe above�mentiOneA
pmperiy for inspenclion purposes . . .'
Date: "� _ SignaWr „A
Driver's License or Social Securiry x: � �
i6aLa6 Wn�te—Buildmg: Green—Cotle Enlorcemem: Canary—HOP���am: Pink—Pevenue; oWenroE—Assessor
CITY OF COSTA MESA – BUILDING PERMIT PERM NO: H 070553
PERMIT NO: B 070553 PLAN CHECK NO: N GOVT; N SUPP: N
CONSTRUCTION TYPE: PERMZT TYPE: STA PURPOSE: OTH
JOB DESCRIPTION : T/OFE REAOOF W/COMP SFIZNGLES SQ FT; 2,000
CLAIM VALIIE: 2,000,00 CALC–VALOE: 2,000.00 GAOUP OCC; R-3 /
*�*******�r+Sr+Mr�***Dwrrw�*****#****D***�****B�4x«**���*�**�w**D*�*****r******r*r+r�r
Z O N I N GS ERTEBgAUCIKRSE M E N T S�pAf�p,o� Fi���ClOR
tdi\.,sP( Ca
------------ MAIN BUILDZNG ---------- --------- ACCESSORY BU��� ,�N–
FRNT; FT IN REAR• FT IN FRNT; FT IN REA : ��
LEFT; FT IN RGHT: FT IN LEFT; FT IN AGHT: FT IN
PARKING REQ: PROV; PARCEL; 42215105 2NE: AEF NO;
PLANNING NOTES>
>
*�r**�r***+r*�rit*it**it�r**�rr*�irit*�r*�*�ir*rir*ir�x w*+t�r*�*�*w*��ir�r*��r�r**x ****+r****�r�*r�**�r
D E V E L O P M E N T S E R V I C E S R E Q O I R E M E N T S
20NING APPROVED BY .
BUILDING APPROVED BY ;
APPLICATION ISSUED BY:
ifitifkitfFififiFifif%ifMilifitl!#flM�t
DATE; _
DATE;
DATEe �
te w�! 1F fF h 1F 1F iF 1F it iF 1F if 1f ii 1F iE if �f 1F 1f if iE
%iF 1f 1F if iF 7f 1E i! 1f i! �E ff iF iF M 1f M if 1! ik M if if if 1ElE 1f �E if 1f if iE jf if if if 1f 1f 1f iF if iF 14 if iF M M if M iE Mif if iF iF if aF 9F M iF fE iF it 1F fF aF if !F 1f 1F if iF it if M 1F iE 1f
LEGALIZATION:N F E E S U M M A A Y STRUCTURAL SEGMENT:Y"
---r .�-, • +
BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP%RES�� GRADING'�
PERMIT 45.00 _gp• .� • .,
PLAN SMIP/NON–RES ,
..�.
ISSUE FEE . `� -
BUILDING–DIV–> PERMIT ISSUE PLAN–CHECK TOTAL. PAID';'.�� - DUE
TOTALS----> 45.50 0,00 0.00 95.50 _45.50 .� ,00'.
REVENUE DIVISION TOTALS--> COLLECTED; 45.50 OVER/SAORT:'� �.00•�
BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAPI–CHECK-�,
45,�� ,S� _ '
ifMlhMif4iflF�fklfiFifififMifflifMklfililMifMiflkiFitlfiEififffififlfltiflklfMYifMkMM1F�f1h�FMMfkififk4lE�ifYifiFif�lflfifitMiflfif.lfitiklf �•
I N D I V I D U A L F E E B R E A K D O W N •
�' - . • . . �
TYPE QTY D E S C R I P T I O N UNIT COST � TOTAL�COST
SFR 2000 REROOF BY VALUE RESIDENTIAL NOZONE 1,00 �
/ END OF FEES
� � -�Isi� oT' -�.�<. ,�p�, �� `;
� rC+^�l %—'e d• � j S P-Q /"�k r` - /�� 1 Q�
Q/A' —
s�t �cl� rfl�t air► va.�'d °� :� s 1��41 .:.
� n�cusT- b� co��o%e7`Qd �v ' BEc2 s �9sa ..< �2 .
/a.7`e�- �a+1 `/�ua•-y / l �t'Q� pF COSTA ME,SA
�. ����`"�`� 6/�y�9r:
__ •�
� 2,000,00`;
' l , � .
` _ '. __ .
1
�.. . -
� CONSTRUi1710N',�ND PLANNWG POO � tPq 1 i (
Oate Inspector Date (InsPector �
APPROVALS Permit# � APPROVAIS Permit?k � �
�
1. Temporary Electrical Service or Po1e 52. Pool & Equipment Location �? i '� �
i r
2. Soil Pipe�Und�gCnd_. 53. Steei Reinforcement `� � � .'
-t_•�. r.i
.�.3,. r� - f.�. . - v
;�lectncal Concruif��Ut�I�ty�Und�grnd. 54. Forms \ �
ti��il Eiectrt�al CondLfF=Undrgrnd. ' 55. Electrical Bonding � � -.
' u' n T
?j 5�,.'��`teel Reinforc2ih�y�i 56. Rough Plumbing & Pressure Test }' '
::6:�iEctr:cal UFE'RGfnd. 57. APPROVAL TO COVER�GUNITE ` ��
-. .. I
.,��'���_�qbtings '�.�j ' 58. Etectrical Gvnduit�Undrgrnd. { �
8;�-Foundation �� � 59. Gas Pipe, G� Undrymd., Tesc � '�� .�
- �.
9. VJa`ter Pipe-Undrg�nd. 60. Backwash lines, P-Trap, L�. Undrgrnd. �
i
10. Structural Floor System - 61. APPP,OVAL TO DECK� � � j
71. Prdperty Sewer Linej& House Connection ' 62. Backvvash & Receptor�Final ,�-� "- i
72. Sewer Cap - ^ y 63. Heater & VenrFinal -ti
13. Roof Drains `� ?? ` 64. Plumhing System - Final ��Y �
14. Rough Plumbi� " � 65. ElectricabFinai .- !
75. ftough Electrical-Conduit 66. Solar SYstern-Final -� �
I
16. Rough Electric Wiring 67. Fencing & Access Approvai j.
i7. Rough Wirinq Sig� 68. APPROVED FOR PLASTERING
17,8. Rough Electrica�T Bar Ceiling 69. POOUSPA SYSTEPBS FINA� j �'
19. Rough Heaung & Air Conditioning FIftE DEPT, ftEQUIREMENT � �
-. - . ,� �. -� .. . ... .. "7 ,. _' P :. ry' n ,-� ":' � �
20.rRough Facm� Fii��lace •b; '4" . J � ' APPRQ,VA�;S� -' �Per�r�"iit # ° �" r" .. ' �
rs.� � -'' -^.t ,) .'�-:�, -'--i"'_
21.,�ucis.irrStrnytuee;• •����1 .-i._ �. ' ,'+ .-+.+* 70.UndergroLndiHYdo > ' I
<
22. Duc{5, Vkntiiatiny' � " �� =� �� ° '^/7. Product.{��irj9 ��G:is �',bii ' ' ' �
.,
23. Gas �ioe'_Rough & T�est i ,,-:� � -q �� „ �J� ; �72. Undergroiv�d Fiu=.h'�= - �- � . .,
24.=RoofFreming- , �' � y'� � �, H� � :?3.��lndergrnd;Stor%?�"_Cai:kQGas ❑Oti � ! ' ,
`�t. �. � �
25. Roo`�Stie�athing ?;T �� f'�_ �p,-`t-�.J �tv�a "74.�'Qverhead fiydro�... � � ', . ` ,
- ' , i
26. T�Bam Ceiling (StrGLturali & Wonocoat + _ � " C'] � ; 75.'�UlY Chemicai �� t � ' �F' '
27. -Frame ar�� Fiashi ga -� .: = v � 7 �-;� �;;.-. .-� : ' _ _ : .
e CS^.. r. U 76. Dry S2andP�pe �-r�i +
�
28, lathing�& SitBng�; • -� '1�;7: * � ' • i "� � � 77, �'FIXED SYSi'Eh��F�FNALk " � "" � I�.:
n.
=29. Insulation -. "� .. '' ' ' .. r ' � �p < 78..=FIRE PREV. FINFtt � . _. � �T` .•
�30. Drywali�Nailing �j'y � � � `y � _' HfALTN'pEPT�RfQUIR�7�lENT� ; �� �.
37. Piaste�Brown�Coai. <, i�-•��. � I ja :;:79.'FINALIN&R CTl4N a� ` �. � ' I
� w t �-Y .
32. �Electncal Power M ter.�Flnai i ' "� I + ' :80.'�00� CERTIPIGATE IS�U�D � '� �� '�
; . � � . _ -- _ ., � ��:4�:��:-:_:.:. •
• -, " � �.. ' T • [ [1 T ".� j 11 /4 �"i
33..F.in�(�Elec,ric : �. �. , p ; �fi ,, �Jo£e5� -j,- - � ;�Sp; �`}= 7Y
-' •'---• ____•_---�'.""'r,,-�,-r•--k�
�34. ,PinaCHeating $� Air Condrtioniag = '� R � � j ri � ��' _ C. � } _ -7 �' ,,.,} i►:�"
i i �. v ri e--�: t :n ..�1�:
y�5.;FinalGdS�Pip2;Testi '. 7 �: � j IE ' :r: rj,-S� �r �_;i.� �ni�
'? ..-t �ty'.
, - : rr. '�.. � .a,..
� : � _ '•i • r-� , '. �i..'
86. NooiJ, or �CanoPY u; a = � � , -5 •- . . . „r . - _ � � s ' � � :�s - � � �` �
_ _ �•,rr �:� I I.� _•.J F .d _ ��`.
�J. dinat�Factor Fire tsce' '" � "' � . ' J . .
. C. . , Y R '�-. > I r � k � y � L- ', .
� . '-�__ ._ z_ 1 .
28. Final:Plum6ing ,�1- ' � " � f - �' ' � .' � .,_ ��.
i i r rr � n
39. Wat£r�Service:PinaP' � .• � � .'; - .' '.i , '�'^' . .
�, i r. i ,� . • - ��� ' '+ -
r i. � ,^..
40. Gas Service-Frnal ., --�„ - ,n i : ': �'�,,, `.;^: ` . . . ?x�� : :
. . .. .. � � i. : . �:.. ; ,�� =�=-c,.
4,1. Solar pomest',c-Fin'sl `� r� " r'k � � �� ' �r =:v ma � . r4� �
� � �' .� ' . . . _.. ,
'42. Backflow Preventeri> �t _ � �� �:;7� �j '�� .-`��Y C' �� � _ [� ��' ;� I
._ � � � 7 a -
43. Backflow Irr. ation a ... �`: '-=: + " - r'... ' � / "/���4"� �' "��
g; �; a. f rl; i' �� �r�� ,�![/j/�: �' �
i
� � -�-4����
4/3. Landscape IrrjgatidrtSystem�,^.: �� , a ;� 7 '�*- ' - �' � �
' + n t c Q_. �4 !�-L
45. Sound ALte�uatioti � : � ' � F r• � + � : � - � ^ .+ �•� a r'� .'
c.,i
; . : r ��i � o � -� l¢�l,L-' � _
s , , , Y�;-�,--- ; -�----- ,� --}��...-���,
46. NandicaP.Regulatiern ^: _ • . . , �+ r ; �p��10�r,� µ1��„ rAn_"��•
--���
47. k�iN/�LSTRUGTUfl£&BUILDWG Y L7-� � i" - .':;' • ' .
� s��e.rw�; s �0.l r�e.�. a��
C8. �FlNALPLANNING� �� � • ... f� � �^�l� r�`
` , ,, - � d� s1�d,G(
49. Etectric Release to Edison ' ? '
.. .. . � ,, : �s.t�2 r �l .'�,,"^-� S � � --'�`f�__Y_9_ •
50. Cras Retease to Southem Califprnia Gas Co > �- t-� .. C_ ". ���. �������
, �, �_
51. CERT;IFICATE OF OCCUPANGV� + � /�� -y^µ� � > / �
No. Date � � - J
_ . ,
� • � t�2w;,+ `- CS`1oS53
�13 0��, s-r ,
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CITY OF COSTA MESA
BUILDING DIVISION
OWNER-BUILDER VERIFICATION
A city or county, which is required to give notice pursuant to Section 19830, shall attach to such
notice, and, as a condition precedent to issuing a building permit, require the completion and require the
return of, an owner-builder verification.
Attention Property Owner:
An 'owner-builder' building permit has been applied for in your name and bearing your signature.
Please complete and return this information in the envelope provided at your earlies[ opportunity
to avoid unnecessary delay in processing and issuing your building permit. No building permit will be issued
until this verification is received.
1. I personally plan to provide�ie major labor and materials for construction of the pro-
posed property improvement.l`�] Yes ❑ No
2. I(have/have not) �_ signed an application for a building permit for the
proposed work.
3. I have contracted with the following person (firm) to provide the proposed construction:
Name
Address City
Phone ( ) Contractor's Lic. No..
4. I plan to provide portions of the work, but I have hired the following person to coordinate,
supervise and provide the major work:
Name
Address City
Phone ( ) Contractor's Lic. No..
5. I will provide some of the work but 1 have contracted (hired) the following persons to pro-
vide the work indicated:
Name Address Phone Type of Work
I hereby affirm that I have received a copy of the information set forth in Section 19830 of the State
of California Health nd Safety Code and have completed the above information to the best of my per-
sonal knowled e, i com li nc w p �qs t e law. 1 (� ��/
Signed: 9��������J�1'� Date: `�'�"'-\—\
Name: �����4( vV \ V� � � L.F'
(Printed or Typed)
C.D.L.NorS.S.# ����"\� ��./
754-5273
i oa2 as
JOB ADDRES:
GENERAI, CO�.
AP. No.
INSPECTICJNS
Joann:: St.
'Ott Ownrr-Bldr.
LOT R TR�
POWeT
DATE
FIRE
SUBCONTRACTOR
VALUE $ 101.00
3IPTION OF WORK nc
TYPE
Farm 210-3M-4�59 ZOClSZ
6 6 -
v
Q o
Q
,: � 10�:�2
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O. BOX 31� COSTA MESA. GALIFORNIA
FOR APPI/CANT TO F/LL /N COMPLETELY
n TYPE OR PRINT
ADDRE'S5 "p PGMC�'A"-'T
COSTA MESA, CALIFOF2IJIA
OWNER �L �� rL_ �_
MAIL / �
ADDRE55 S�U w' `� � aL-� CiI.J
TEL.
cirr .�-'Atl�i N ./G //�
ARCHITECT LIC.
Or �INEER . NO.
ADDRE55
LEGAI I LOT � I I 1a
oescairnorv NO. BLOCK TRAC'
A.P. NO.
SIZE NO.OF BLDG9.
OF LOT Cv�B 7� �G'U HOw oH �oT
SETBRCH LINE FROM
c[HieA ov sTRe[T �'[� � REAR YAF
I
SIOE YARD ILEFT � RIGHT I
DESCRIPTION OF WORK.
REPAIR I II MOVING I
BUILDINCxq NO.OF
SRE C�%1C'�G- ROOMS
. EXTERIOR W0�C'� ROOF
COVERING J/t�CCG' COVERIN
115E OF BUILDING ANO WORK TO BE
a Y•
I HEREBY ACKNOWLEUGE THAT I HqVE PEFC THIS APPLICATION
RND iRTE THAT THE RBOVE IS CORFECT AND AGFEE TO COM-
PLY WITM RLL CITY pO1NRNCES AND STqTE LqW pEGULATING
BIIILDING CONST C ON.
SIGNATURE F
PERMITTEE
AUTHORIZED AGENT
a;�� RECEI��D
�=':J Y �.� y - j -��
APP `GY�Tj���j�li,.T��.ERMIT
�� BUILDING J�
foR offic� usE oNcr
I NECEIP� NO. I F�R�`��
/
IVFD BY I DATE ftECEIVEO I DATE I65UED
COSTA MESA, CALIFORNIA
FIRE
ZONE T
APPROVED
BY
ZONE . INO.OF
PLANS
APPROV D 1
BY
YARDS
REQUIRED
ICENTER LINE ST.)
FRONT
R.SIOE
L SIDE /
I�SE OF NEW �
BUIIDING
DA � �'
EV 5
ALLO W ED
FT. /_�p/{�' i IN.
FT. I N.
F'f. /1�Y i�/ IN.
THE AMOUNT SHOWN UNOEN V.�LUATION IS FOR THE
PUFPOSE OF ESTABLISHING A PERMIT FEE ONLY.
VALUATION � —
� PERMIT FEE S
/�/� PLAN CHECK S �
$
� �i
TOTAL FEE 5
= 1�� 3D �._Aus i a ie��
COSTA MESA BUILDING-SAFETY DEPARTMENT , � "" • "- �
P.O. BOX 317 COSTA MESA. CALIFORNIA .
FOR APPL/CANT TO f/LL /N COMPCETELY APPLICATION FOR PERMIT
TYPE OR PRINT BUILDING
BUILDING
ADDRE55 �/JL� rAD �U
COSTA MESA, CALIFORNIA ryn OFFICE USE ONLI
�' I RECEIPT NO, l-., P(ii��0.
OWNER �_j r
MAIL RECEIVED BY D�TE RECEIVEO I UATE ISSUED
AODRESS �°S—j 'J S I 6�LZ�
TEL. BUILDING
CITY ({� NO. ADDRESS
ne���7ec7 ��c. COSTA MESA. CALIFORNIA
O! aINEER NO. �/
ADDRESS FIRE t' //�
ZONE TYPE GROLIP r
STATE APPROVED
CONTRACTOR Wi LIC.NO. �O BY DATE
wooRess ZONING
LEGNL I LOT I I'��Co O ZONE NO. OF q/ JtUSE OF NEW
DESCRIPTION NO. BLOCK TRAGT �t IPLANS ' IBUILOING ,x
APPROVED
A.P.NO. BY DATE
SIZE rvo.oca�ocs. ypRDS EVES
OF LOT I�( b O I Now oH Lor -� REqUIftED ALLOWED +
USE OF � (LENTER LINE 9T.)
EXISTING 9LOG. FRONT FT. IN.
SETBACK LINE FROM /j� � t
CENTER OF 9TREET �v REAR VARO�� ' R. SIDE FT. IN.
i
SIDEYARD ILEFT 7 1 (RIGHT � L.SIDE �� FT. IN.
DESCRIPTION OF WORK
REAR FT. IN.
NE\" � I� II ALTERATION I II ADDITION I
REPAIR I IIMOVING I IIOEMOLISH I
5 ZIE DING �r�X y O ROOMS STORIES �
'J L
EXTERIOR WA L ROOF O-iSe Sy} ��-'4�Y
COVERING i�/GLO ICOVERING Q ILoG.1L_
USE OF BUILDING AND WORK TO BE PERFORMED D /
� — �d'7� � / 7 J � ' �.f
�S''� -
�'�i � — �
1 HEFEBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION 7HE AMOIINT BHOWN UNOER VqLl1pTION 18 FOR THE
pND STATE THAT THE ABOVE IS CORFECT ANO AGNEE TO COM-
PLY WITH AlL CITT OROINqNCES RND STqTE LAWS REGULATINC, PUPPOSE OF ESTABLISHING A PERMIT FEE ONLY.
eU1LU1NG CON RVCTION.
/ VALUATION `J �O
SIGNATURE �/_ � PERMIT FEE $ �/ �
PERMII'fEF L L�W�B' /
$ /7 � /� � PLAN CHECK $ �� � v
v(v
AUTHORIZED AGEN
TOTAL FEE $ `5 �^ ��