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Home My WebLink About682 JOANN ST - Building PermitsAoo��ant to fill in al1 spaces exeept tnose witnin neavY Oortler lines ana si9� all aDoropriate tleclarations. CITY OF°COSTA MEcSA CONSTRUC�ION PERMIT PER IT NO. TRACT NO. LOT NO. UNIT N� ��'rojectAddress �pa �OLlnn � Applicant'sMailingAddress SflrtE_ Owner's NameT � o'�.v �... csr� t- Phone S�Ia � R� �g —��1# i� Address 6$ a S e- (� n Arch/Eng. License No. Address 5 R� -�351i Contractor'sNam � L� 1 Phone,� S Addresslmailing) ��+� A.�-nT��C.�,"�B•��-�f Citv License No. �� 1 -i'� LICENSED CONTRACTOR DECLARATION I hereby af(irm [hat I am licensetl untler provi5ion5 ot Charte� 9(commencing with section �000) of Division 3 of the Business antl Professions Cotle, antl my license is in full force antl effect. License CI ss � �y Lic�ense`lNo.� Date "� �hAy � 5'9 t 1-/�udu Yts•�7F�� WORKERS' COMPENSATION DE ARATION V "�hereby affirm that I have a certificate of consent to self-insure or a certificate workers' compensation Insurance, or a rertifietl copy thereot (Section ;00, Lab. C. c. Policy No. 3� I�n Company��rmen� ZNIJ�OP� �Certifietl copy is hereby fumlSheC. Gertit'etl copy i filetl with the city 'Itl� �ivi ion. Date3�MA�/ �Q6 qpplicant EXEMPTION FqOM WO(3KER5' COMP NSATION DECLA0. ION (This section neetl not be completetl if the permit is tor one hun retl ($100) or less). I certify that in tne performance Of the work tot wM1ich this pe�m�t is issuetl, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of Calitornia. Date Siqnature NOTICE: If, a([er making lltis tleClaration, you shoultl become subject to tbe Wo�kers' Compensation provisions of the l2bo� Co�e, you must /ortnwi[h comply with such, provisions o� this pe�mit shall be tle¢metl revoketl. CONSTRUCTION LENDING AGENCV 1 hereCy atFl�m ihat Ihere is a const�uc[ion lentling agency far the perfo�mance of the work for which t�is permit is issuetl (Section 309� Civ. CJ Lentler's Name �Lentler's Atltlress OWNER BUILDEH �ECLARATION I hereby aifirm that I am exempt trom tne ConVactor's License Law tor the following reason (Section 7031.5 Business antl Professional Cotle: Any city or county wM1ich requires a permit to con5truct, alteq improve, tlemolish or repalr any structure, p�io� to i[s issuance, also requi�es the applican[ for SUCh pe�mit to file a si9netl statement that he/she is licensetl pursuant to the provisions of the Cont�actor's License Law (CM1apter 9(commencmg with Section ]000) of nlvi5ian 3 of the Busine55 antl Professions Cotle) or that he/she is exempt arefrom antl the basis for the allegetl exemption. Any violation ot Section 31.5 by any appllcant tor a petmit subjects tne applicant [o a civil analty of not more tban five huntlretl tlollars ($500). ❑ I, as owner of tne property or my employees with wages as their sole compensation, will tlo the work, antl the siructure is not intentled or otferetl for sale (Section 7044, Business antl Professional Cotle: The Contractor's License Law tloes not apply to an owner oi a prooerty who builtls or improves thereon, antl who tloes such work himself/M1e�self or throuqh his or har own emplovees, proviaetl tnat sucn improvements are not intentletl or oiferetl for sale. If, however, the bulltling or improvement is soltl wlthin one year of com- pl¢tion, tne owner will have the burtlen of proving he/she tlitl not buiitl or im- �roye tor the purpose of sale). 1, as owner of Ihe OvoOerty, am exclusively cont�acting wlth licensetl com [ractors lo construct the project (Section 7044, Business antl Protessions Cotle: Tne ConVactor4 License Law tloes not appry to an owner of property who builtls or improves [hereon, antl who conVacts for such projects with a con- tractor(s) 1¢ense pursuant to tM1e Contractor's License Law). I am aware Ihat D/oof of their Worker's Compensation insurance shoultl be provitletl to me. ❑ I am exempt un0er Section B. & P. C. for this reason Date $ignature 'Drivers' L 3 S TVPE OF CONSTRUCTION NEW ADD ALTERATION REPAI R ❑ CONVEft510N ❑ DEMOLISH ❑ OTHER A p # DESCRIPTION OF WORK/USE OF BLDG. S Main Building: E TVPEOFPERMIT GRADING ❑ FOUNDATION STRUCTURAL T F�Ont ❑ TENANT ❑ ELECTRICAL ❑ PLUMBING ❑ MECHANICAL B Rear ❑ OTHER %� PROJECT DESCRIPTION SQ. FT. OCCUPANCV C Ri9ht K Left CONSTRUCTIONTVPE VALUATION$ $ ZONE GRADING CLL VDS. ACRES p�ng. Ref. # Remarks: Planning Notes: Owner certify tha[ 1 have reatl tttis ap0lication antl state tM1at the above ' �n i5 rorrecL I agree to comply wrth all city antl county ortlinances laws relatin9 to builtling constructlon, antl hereby authorize repre- of this city to 'enter upon tM1e above-mentionetl property for p o Date .ice e or 55 � 3ar Sink 3ackflow Preventer 3ackflow Irrigation 3athtubs - � Clarifiers Dishwasher Drinking Fountains Floor Drains Floor Sinks Gss Service Outlets Interceptars Kitchen Sink Lavatories P.-Trap Roof Drains Reinspectian Fee $15 Boiler Duct- Under Ground Duct - Sttuctural Duct -.Ventilatin9 Ezhaust System ❑ Multiple Firepl/FacL Blt. ICBO # st & Ductin9 0-100,000 BTU O 100,000 Reinspec[ian Fee � $7b CMF 0865-46, rev. 10/84 White - Builtling; Canary - Applicant; Pink - Accounting; Goltlenrotl - Azsezsor PLUMBING Showers Service Sink Sewer Cap Sewer Connection Solar Collectors Solar Pipin9 Solar Tank Swimming Pool w/Spa Urinal Water Closei Water Heater Water Service Auro-Wash Laundry Trays Issue Fee Hood or Type I ❑ Canopy Type II ❑ Refrigeration Sys[em ❑0-100,OOOBTU ❑t00,000BTU System Repair/Alteration Fire Dampers Registers Issue FEES Automatic Washer Construc[ion Poie Sub. Cooking Unit Dishwasher Dryers ❑Gas ❑ElecVic 980G ='�e� i T� ' ' � . Zone � - Accessory Building: Z O N � N G H Parking Req./Provided E Q M T S ELECTRICAL Transformer ❑ 15-50 KW ❑ 50+KW Fan F.A.U. Fixtures Device Boxes Outlets $wiahes Garhage Disposal Generator DO-5 KW �5-15 KW Meter ❑up Lo 100 amps Meter ❑over100amps Su6 Panel Motors �0-7 HP � 1 Yz - 8 Inc.Solar �9-15 HP 016-1 Microwave Pole Light Si9n ' Standing Section: Trash Compacior $�� Reinspection Fee $15 Issue Fee FEES �DEVELOPMENTSERVICESREQUIREMENTS: Zoning Approved By Building Approved By Application luued By � � FEES $ 3 . SUMMARV OF FEES � BUILDING PERMIT $ SMIP $ PIAN CHECK $ PERMIT PLUMBING $ ISSUANCE $ PLAN CHECK 25% $ ENERGY P.C. $ ELECTRICAL S GRADING $ PLANCHECK 50% $ __.,/__.� MICROFILM $ � MECHANICAL S �t`f�U TOTALFEE $ �� PLAN CHECK 25% $ � CONSTRUCTION ANPPLANNING POOL & SPA " Date Inspector AppROVALS Permit# Date Inspector !lP,PROVALS Permit;� 1'�Temporary Electrical�Service or Pole 52. Pool & Equipment Location . � j, 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, O Undrgrnd., Test 9.�Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap, O 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 �8. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL • .r ,�9. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT � r'� : 20. Rough Factory Fireplace APPROVALS Permit # �21. Ducts, in Structure 70. Underground Hydro 22: Ducts, Ventilating 71. Product Piping �Gas ❑Oil 23. Gas Pipe-Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd.StorageTank �Gas ❑Oil 25. Roof Sheathing, . 74. Overhead Hydro 26. T-Bar Ceiling (Struciural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe ` 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. In�ulation 78. FIRE PREV. FINAL 30. Dr{�wall Nailing HEALTH DEPT. REQUIREMENT n.� 31. Plaster Brown Coat 79. FINAI INSPECTION {' . ., 32. Electrical Power MeterFinal 80. FOOD CERTIFICATE ISSUED �Y� 33. final Ejectric Notes: (i 34. FinaliFieating & Air Conditioning � � �j , � � ✓ 35. Final�Gas Pipe-Test 36: Hood or Canopy , ' - " 37.� Final Fac[ory Fireplace _ ; �' 38. Final Plumbing ! ' L�' 39. Water Service-Final . � ' " ' 40. Gas Service-Final �� - � .. 41. Solar pomestic-Final . �-. � � ' i �42. Backflow Preventer . _1 ' �" `' . .�i �'43. Backflow Irrigation ' f � � ' `, ' : � 44. Landscape Irrigation SYstem ' .� , � , . �, ' ' 45. Sound Attenuation � " � � A� 46. Handicap Regulations � ' . � - ' . . r 47. FINAL STRUCTURE & BUILDING � • • � � � 48�Special RequirementsCompleted _ - -� ' '49i Electric Release to Edison i J ,i 50. Gas Release to Southern Califomia Gas Co � �_� %� 51. CERTIFICATE OF OCCUPANCY No. Date � � " ' I�� Applicant lo fill in all spaces except those within neavr border lines ana sign all aooropriate tleelarations. Ci7Y oF coST,a MESq CONSTRUCTION PERMIT Projec6Address — 6 8� Toq�, n� ��/J � Applicani's Mailing Address RA n� F- �Owner'sName �._�e-�1. • Cfl.t' �..�.�+r PhoneSHa—AT I$ Address 6 8 s ��+ � � � �i Arch/Eng. Licenu No. Address Convactor's Name� D'`�' Phone a as -3s b Addresslmailingl.6�-FiJ 1��,.��.. _�;_Dr. �B.,a..... Q�rk City License No. y- �—'J� �'I � LICENSED CONTRACTOR DECLARATION I nereby affl�m that 1 am licensetl untle� provislon5 of ChartE� 9(commencing with section 7000) of Diyision 3 of [he Business antl Professions Cotle, antl my license is in full force antl etiect. License C ass — ��cense Ng.34 �t� Oale Si9nature V�a e WORKERS'COMPENSAT�pry OEC RATION• s ' h¢reby affirm Ihat I nave a ter[ificate of consent to self-ins4re or a ce�tiflcale Workers' Compensation Insurance, or a certlfietl coOY thereof (Section .800, Lab. C.) Policy rvo.F3r,yo�, COmpany Fo��«�fi..� =ti%urr.n� Ccrtifietl copy is hereby tu�nishetl. Certifi�f copy Is filetl With tM1e city Buil ' blvi oate 3//�AA�I �vL qpplicant E%EMPTION FROM WORKERS' CO ENSATION DECL RATION (This section neetl not be completetl if he permi[ Is for one huntlretl ($100) or IC55). 1 certity [na[ in the DetfoYmance of tne work fo� whlch [his perm�t i5 issuetl, I shall not emplOy any persan in any mdnne� so as to betome subject to (he Worke�s' Compensation l_aws ot Calitomia. Da[e SignaWre NOTICE: If, after makin9 tnis deciaratlon, you shoultl become subject to the Work¢rs' CompCnSation provisions of the Ldbo� Cotle, yoU must tortnwith comply with such O�ovisions or thi5 pe�mit sttall be tleemetl ravoketl. CONSTRUCTION LEND�NG AGENCV 1 hereby aifirm that there is a conz(ruction lentlin9 a9ency tor the per(ormance ol tne work for w�ich this permit is i5suetl (Section 3097 Civ. C.) Lkntler's Name Lentler's Atltlress ' OWNER BUILDEH �ECLARATION 1 hereby affirm thdt I aT exempt from the Contrdc[or4 License Law for [he tollowing reason (Section ]031.5 Business antl Profassional CoOe: Any city or counly whlcM1 rCqui�es a permit lo Wnstruct, alteq Imprave, tlemolish o� repair any structure, pNor to it9 issuance, also requires tha appllcant for such permit lo tile a 5igneU Slalement that he/she i5 licPns¢tl pu�suant to the provisions ot the Contractor'S License l.yw (Chapler 9(commencing with 5ection 7000) of ivision 3 0l the Busin455 antl Profezsmn5 Cotle) or [hat he/she is exemp[ 'U�erefrom antl lhe ba5i5 fo� the alleqetl exemplion. Any violation of Section �t' )31.5 by any applicapt for a permit subjects the applicant to a civll =�enalty of no[ more [nan tive huntlretl tlollars (g500). ❑ 1, as Owner of [M1e property or my ernPloyecs with waqes as their sole compen5ation, will tlo the work, antl the structu�e I5 not intentletl or ofte�etl for sale (Section ]044, Business antl Professional Cotle: The Contra<[or's License l2w tloes not appry to an owner of a proparly who builtls or improves thereon, antl who tloes such work nimseli/herseli or tnrough his or her own employees, prodtletl tbal zucM1 improvemen[s are not intentletl or off¢retl for sale. It, hOwever, lhe builtling or imp�ovement I5 soltl wi[hin one year Of com- pletlon, tne owne� will have the burtlen Of pwvin9 he/she tlitl m[ builtl or iT- �ove �o� Ihe purpose of 4ale). LI I, as owner o1 the prOperty, am excWsiveiy contractin9 with lirensetl con- tracrors to con5[ruct the Uroject (Section ]044, Business antl Proie55ion5 Cotle: The ConVactor's License l�w aoes mt apply to an owner oi property who Duiltls o� improves [M1ereon, an0 who mntracis for such Oroje[ts wilh a con- tractor(s) ntense oursuant to tne ConVactor's Llcense Law). I am aware that prooi of tM1ei� WorkeYs Compensalion insu�ance Shoultl be provitletl to me. ❑ 1 am exempt untler Section 8. & P. C. Por this reason TVPE OF CONSTRUCTION Ll NEW U AD� LJ ALTERATION LI REPAIR ❑ CONVERSION ❑ DEMOLISH ❑ OTHER q,p.# DESCRIPTION OF WORK/USE OF BLDG. S Main Building: TVPE OF PERMIT GRADING FOUNDATION STRUCTURAI T Front ❑ TENANT ❑ ELECTRICAL ❑ PLUMBING ❑ MECHANICAL A Rear ❑ OTHER PROJEC7 DESCRIP710N SQ. FT. OCCUPANCY C Right K Left CONSTRUCTIONTYPE VALUATION$ $ ]ONE GRADING CU. V�S. ACRES Ping. Ref. # Remarks: Planning Notes: Date Owner ' I M1meby certify that I have reatl this application antl s[ate tM1at the above Information I5 correct. I dgree to comply with all tlty antl county ortlinances antl state laws relating tp builtling conslruction, antl hereby authorize repre- Senlatives o/ this cHy lo ente� u00n the above-mentloneG property for inspectlon pur os ('�,� w Siqnature o.awAyV �1M�—+'�� :-�.^ 3ar Sink 3ackflow Preventer 3ackflow Irri9ation 3athtubs �larifiers Jishwasher Jrinking Fountains Roor Drains Floor Sinks GasService Outlets Interceptors Kitchen Sink L'avatories P—Trap Raof Oreins Reinspection Fee $15 Ducl - Under Ground Duct - Sttuc W ral Duct - Ventilating Exhaust System ❑ Multiple ❑ Firepl/Fact. Blt. IC80 # in S st Ducting 0-100,000 BTU 0100,000 BT Reinspection Fae � g�s CMF OBfiS-46, rev. ]0/84 White - Builtling: Canary - Applicant; Pink - Accounting: Goltlenrotl - Assezsor Showers Service Sink Sewer Cap Sewer Connection Solar Collectors Solar Piping Solar Tank Swimmin9 Pool w/Spa Urinal Water Closet Water Heater Water Service A uto-W ash Issue Fee Hood or Type I ❑ Canopy Type II ❑ iefrigeration System 7o-ioo,000aTu ❑ioo,000aru System Repair/Alteration Fire Dampers Registers Issue Fea 9807 5/[13/L';: 2��0, i. Zone Accessory Building: 2 O N I N G R Parking qeq./Provided F Q M T $ ELECTRICAL Automatic Washer Transformer ❑ 15�50 KW Consvuction Pole Sub. � 50 + KW Cooking Unit Dishwasher - Dryers �Gas ❑Electric Fan F.A.U. Fixtur¢5 Device Boxes Outlets Swi[ches Garbage Disposal Generaror �0-5 KW �5�15 KW Meter LJup ro 100 amps Meter ❑ov¢r 100 amps Sub Panel Motors �0-1 HP �1'/,-8 Inc.Solar �9�15 HP �i6-75+ Microwave Pole Light Range Sign Standing Sections Trash Compactor FEES $ 3 Reinspection Fee $15 Issue Fee $ 3 FEES DEVELOPMEN7 SERVICES RE�UIREMENTS: Zoning Approved By Date Building Approved By Date� Appliration Issuad 8y Date��jf y�� SUMMARV OF FEES BUILDING PERMIT S SMIP $ PLAN CHECK $ PERMIT - PLUMBING $ ISSUANCE $ PIAN CHECK 25% $ ENEIiGV P.C. $ ELECTRICAL $ GRADING $ - PLAN CHECK 50% $ MICROFILM $ —��/�/�/— MECHANICAL S � TOTAL FEE $ � g� PIAN CHECK 25% $ % CONSTRUCTION AND PLANNING POOL & SPA APPROVALS Permit# Date Inspector AppROVALS Permit# Date Inspector . � 1� �Temporary ElectricaV�Service or Pole 52. Pool & Equipment Location t� 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 ��ootings 58. Electrical Conduit-Undrgrnd. 8„�F.oundation �;,J 59. Gas Pipe, O Undrgrnd., Test 9.�Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap, � 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_El�ctrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL � 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT - j� 20. Rough Factory Fireplace APPROVALS Permit # 421. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping OGas ❑Oil 23. Gas Pipe-Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank O Gas ❑ 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.. FIXEDSYSTEMFINAL 29. In�ulation � 78. FIRE PREV. FINAL 30. D�ywall Nailing HEALTH DEPT. REQUIREMENT �� 31. Plaster�Brown Coat 79. FINAL �NSPECTION (Y' 32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED � � �„ 33. Final Electric Notes: 34. FinabHeating & Air Conditioning � � -_- 35. Final Gas Pipe-Test 36. Hood or Canopy - . 37, Final Factory Fireplace � � . � • � Y 38. Final Plumbing . ' . 39. Water Service-Final . ' .. . _. . � • i , . _ 40. Gas Service-Final � ' " ' � 1 41. Solar pomesticFinal � i ,,_ � i 42. Backflow Preventer �,, i ,` � _ . , 43. Backflow Irrigation �+� 4, ' � � � 44. Landscape Irrigation System '� 4' ' , � 45: Sound Attenuation � i� � ' 46. Handicap Regulations � � " � . , 47. FINALSTRUCTURE&BUILDING , ' : _ � 48.' Special Requirements Completed • ' �- � 49. Electric Release to Edison •� �' 50. Gas Release to Southem California Gas Co i, y ' „ • 51. CERTIFICATE OF OCCUPANCY / No. Date , �. . �. \,.\�•._( . - 1��_��' COSTA MESA BUILDING-SAFETY DEPARTMENT P.O. BOX 317 COSTA MESA. CALIFORNIA ,, AUG 1 0 iy,;3 - � �- � -3 - fOR APPL/CANT TO f/LC /N COMPLETELY APPLICATION FOR PERMIT TYPE OR PRINT BUILDING eui�oiNc i � ADDRESS f.�L� COSTA MESA. CALIFORNIA fOR OfF/CE USf OM[Y OWNER /L �jM . �e RECEIPT NO. I��RM1'IpN; .�° J MAIL /� RECEIVEO BY I OATE RECEIVEO OiTE I+6�O ADDRE55 � �C.i` iVM/�L d ) TEL. BUILDING CITV h( NO. (I ADDRESS ARC"'TECT ��c. COSTA MESA, CALIFORNIA OR INEER NO. ADORESS 20NE TYPE (/ GROUP tiY � STATE APPROVED CONTRACTOR S LIC.NO. �O BY DATE nooaess ZONING LEGAL I LOT I I�� ZONE NO. OF USE OP NEW /1n OESCRIPTION NO. BLOCK TRACT R� IPLANS �IBUILOING (�Y v�y A.P. NO. APPROVED t BY / DATE V SIZE �+ NO.OF BLOG9. / OF LOT l.. � e O xow orv �oi � REOUSRED ALLOWED USE OF �� (CENTER LINE ST.Jr T EXISTING BLDG. FRONT J// FT. IN. SETBACK LINE FpOM ( 7 G[HiEfi OF BTREET SO REAR YARD R. SIDE � FT. IN. SIDEVARD ILEFT •S� IRIGHT �� L.SIDE S �� IN. DESCRIPTION OF WORK REAR � Fr. iN. NE\' I�I /+LTERATION I II AODITION I REPAIR I II MOVING I II DEMOLISH I BUILDING NO.OF Gg � SIZE �S %1e ROOMS p STORIES EXTERIOR WA I ROOF Q�9� �61lKi�E � i� s� COVERING U�[,.� COVERING C� �� ' USE OF �LILLDING AL N�WORK TO BE PERFORMED ��ai— /�� (!� py � aily V � � ' I HEFEBY ACKNOWLEOGE THAT I HAVE FEAO THIS TPPLICATION yNE PMOIINT 9HOWN UNDEN VALUATION �3 FOR THE hND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM- pURP08E OF ESTABLISHING A PENMIT FEE ONLY. PLY W�TN ALL CITY OFOINANCES ANO STATE LAWS REGULATING BUILOING CON ROCTION. VALUATION SIGNATURE vLIQ_ �� /' C�% _ PERMIT FEE $�� PERMITTEG '�+-eLY� Li� Yti.L � sl/' �/� PLAN CHECK S I�S_Q AUTHORIZED AGENT TOTAL FEE $ S 1_ S O