HomeMy WebLinkAbout1694 IOWA ST - Building Permits(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
BUILDING PERMIT
Job Address: 1694 IOWA ST Status: ISSUED
Suite: Applied: 03/05/2002
Vicinity: RESIDENCE AND ATTACHED GARAGE Issued: 03/05/2002
'Parcel Number: 13906118 Zoning:
Applicant: GARCIA, DAVID ISSUED BY:
Address: 21681 IMPALA -
Phone: 714-968-8754
H.B. CA - Zip: 92646 "
Owner: KOURAKLIS, PETROS ,
Address 1694 IOWA ST -
Phone:
COSTA MESA, CA Zip: 92626
Contractor: COAST ROOFING
Address: 21681 IMPALA ST "
Phone: (714) 968-8754
HUNTINGTON BEACH, CA "
Zip: 92646 License:- 450393
Arch - _ Eng:
Address:
Address:
Phone: _ Phone: '
Zip: -License: License:
SCOPE OF PERMIT
REROOF: TIO EXISTING SHAKE ROOF, 1/2" OSB, 1 LAYER 30# FELT, APPLY -25-YEAR GAF TIMBERLINE
FIBERGLASS SHINGLES. 21 SQUARES '
FEE SUMMARY,
Plan Check: $0.00 - i Calc Valuation: $4,025.00
Permit: $111.25 Claim Valuation: $4,025.00
SMIP Res: $0.50
SMIP Com: $0.00
Other: $0.00
Inspection: $0.00
Total: $111.75
SETBACKS
MAIN STRUCTURE Front 0-0 Rear 0-0
ACCESSORY Front 0-0 Rear 0-0
PARKING Existing: 0 , -Required: 0
NOTES
PLANNING & ZONING
Left 0-0
Left 0-0
Proposed: 0
Right 0-0
Right 0-0
NOTICE: The work authorized by this 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 period 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 inspections 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
6�
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
My workers' comp/, nsa)lon Insurance carder and policy number are: C
Carrier:5 [ 'ice rL/ n1/ /'� Policy Number:
(This section need not be completed irt6e permit is vat ed at one hundred dollars ($100) or less.)
❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California, and agree that If I should become subject to the workers' compensation provisions Of Section 3700 of the Labor Code, I shall forthwith
comply with these provis l...ns. /—
Applicant Signature: �t _ e, Date:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION SrO60F THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES,
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licentt eyrqujsipns of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full
force and effect. Lic. b i � Class a '�.� �r
Contractor's Signature: L242-,— 4, •r_ Date: (9 3 /' Q-1
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code).
Lender's Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirn that under penalty of perjury that 1 am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit
to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).):
❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec.
7044, Business and Professions Cade: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work
himself or herself or through his or her awn employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is
sold within one year of completion, the owner-bui(der will have the burden of proving that he or she did not build or improve for purpose of sale.).
❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ 1 am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires:
Verification of Ownership by (type of document, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this
permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Title 8, California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has e
permit to do such work from the division.
Signature: Data:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response t0 release or threatened release of a hazardous
material? ❑ Yes ❑ No
(Section 25505 of the California Health and Safety Cade requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
............................................ ........................................................................................................... ................... ........... ....................... .................... -..................-............. _................................. ............................ .................................................... _...
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, Or 200 cubic feet of
compressed gas at standard temperature and pressure).
............................................. -........................................................................... ...... ................... ...................................... .... ........... .... ....... .................................................... ............................... ............................................ .........................................
3 Does or will the applicant or present or future building Occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)?
❑ Yes ❑ No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire .
... Department.
..... ............... _.................................. ......................... .................... ..... ................................. ................................................ _...................................................... ................................. _................ _.................. __..........
4 If en RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ NO
_....................._..._............................... ................................_._............................_........................_..._........................................................_................_._..............._.................__..............._..
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication apemlit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? B Yes LJ No
(Section 65850.2 of the Califomia Government Code requires that the requested information be furnished on applications for non-residential building permits).
..................................................... ................................................................... _.................................. ................................... ........... ....................__................................... ................. ........_...._.....................
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No
(If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
.......................................... ......................................................poll..........................................................................................................................................................................................
7 a a permit from the South Coast Air Quality Menagemfornia Heal or other air pollution control district n agency is requiretl for the work which is the subject of this
application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and stale that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes. I agree not to Occupy or allow Occupancy of any building authorized by this permit until final inspection.
Signature Of Leggl Owne (s) Date
� 7� �z- os"'O L
ArldtOr Authorized Applicant Date
CODE 1. INSPECTION TYPE TYPE PATE INTmALS CODES INSPECTION TYPE 261E ILLS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Root 210 Final Electrical
201 Final BIOcktRetaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
PROJECTjOflFSS: 1694 I OWA ST UNIT:
OWNER'S NAME: KOURAKLIS, PETROS FLOOD; AE -37
" ADDRESS: KOURAKLIS, NANCY
1G94 T
COSTAIMESAS
CA 92626
714) 549-0616
ARCHIENGINEER:
ADDRESS:
REG.NO.:
UNIT:
PERMITTEE: PETROS KOURAKLIS (714)549-0616
ADDRESS: 1649 IOWA ST
C,M CA 92626
LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Cotle, and my license is in full force and effect.
CITY LIC.: STATE LIC.: CLASS: EXP;
Date: Signature'.
WORKERS' COMPENSATION DECLARATION: I heresy affirm that I have a certificate of consent to self -insure or a certificate of Workers'
Compensation Insurance. or a certified copy thereof (Section 3800, Lab. C).
POLICY NO.: EXP. DATE:
COMPANY:
:1 Certified copy is hereby furnished. ❑ Cenified copy is filed with the city Building Division.
Date'. Applicant:
EXEMPTION FROM WORKERS' COMPENSATION DECLARATION: (This section needltc be completed if the permit is for one hundred ($100) or less).
I Carl that in the performance of the work for which this permit i iad-Y I not employ any person in any manner so as to become
s ct to the Workers' Comp�en9zrt Laws of California.
Date'. '`3 I _/ Signatur
TICE: If, alter making this declaration, you Should b o e WorkersCompensation provisions of the Labor
Code. you must forthwith comply with such pmvisio or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for
which this permit is issued (Section 3097. Civ. C).
LENDER:
ADDRESS:
OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law for the following reason
(Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct, alter, improve, demolish, or
repair any structure, prior to its issuance. also requires the applicant for such permit to file a signed statement that he/she is licensed
pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business
and Professions Code) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
,}A I, as owner A the property or my employees with wages as their sole compensation, will do the work, and the
L1 structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractors' State License Law
does not apply to an owner of a properly who builds or improves thereon, and who does such work himself/herself or through
his or her own employees. provided that such improvements are not intended or offered for sale. If, however the building or
improvement is sold within one year of completion, the owner will have the burden of proving he/she did not build or improve
for the purpose of sale).
L as owner of the property. am exclusively contracting with licensed contractors to construct the project(Section 7044, Business
Li and Professions Cotle', The Contractors' State License Law does not apply to an owner of property who ilds or improves thereon
and who contracts for such projects with a contractor(5) license pursuant to the Cent ractor�te ense Law),I am aware
that proof of their Worker's Compensation insurance should be provided to me.
❑ I am exempt under Section B. 8 P. C.
for this reason'. y
I do hereby certify that I am aware of and understand the requirements of California Healthantl a Sections 25505, 25533, and
25534 and that I or any future building occupant will/will not (circle one) need to comply with said state codes and the requirements for a
permit for construction or modification from the Air Quality Management District. Residential construction applications are exempt from
these provisions.
Date: Applicant:
hereby certify that l have read this application and state that the above information ntcorrect. rite to comply with all city and county
property
and state ect on purpose to building construction and hereby authorize re esentatives of.Ihis city to enter upon the above mentioned
property for inspection purposes /
at' /D_�/ _ %�1 Signature:
Driver s License or Social Security a:
1641-46 While—Building; Green—Code Enforcement; Canary—Applicant; Pink—Revenue; Goldenrod—Assessor
CITY OF COSTA MESA — BUILDING PERMIT PERM NO: B 06967
PERMIT NO: B 069679 PLAN CHECK NO: N GOVT: N SUPP: N
CONSTRUCTION TYPE: PERMIT TYPE: SIR PURPOSE: ALT
JOB DESCRIPTION T/OFF RESTH & REROOF W/COMP. SHINGLES SQ FT: 2,000
CLAIM VALUE: 2,000,00 CALC—VALUE: 2,000,00 GROUP OCC: R-3 /M-1
COMMENTS: SMOKE DETECTORS ARE REQUIRED IN EVERY BEDROOM & HALLWAY, 1991 UBC
Z O N I N G R E Q U I R E M E N T S
S E T B A C K S
------------
MAIN
BUILDING ----------
---------
ACCESSORY
BUILDING---------
FRNT;
FT IN
REAR; FT
IN
FRNT;
FT IN
REAR; FT IN
LEFT:
FT IN
RGHT; FT
IN
LEFT:
FT IN
RGHT; FT IN
PARKING
REQ:
PROV:
PARCEL;
13906118
ZNE:
REF NO:
PLANNING
NOTES>
>
###############################################################################
D
E V E L O
P M E N T S
E R V I
C E S R
E Q U I R
E M E N T S
ZONING APPROVED BY DATE;
BUILDING APPROVED BY ; DATE;
APPLICATION ISSUED BY: C7_ DATE:
####################################################################### ### ###
LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:Y
BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING
PERMIT 45,00 ,50
SMIP/NON—RES
PLAN
ISSUE FEE
BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE
TOTALS ---- > 45,50 0,00 0,00 45,50 45,50 ,00
REVENUE DIVISION TOTALS--> COLLECTED: ----',*45.50 OVER/SHORT: ,00
BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK
45,00 .50
###############################################################################
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
SFR 2000 REROOF BY VALUE RESIDENTIAL NOZONE
E XP I RED. END OF FEES
f P• to 1rspedi is
�rxorn ) "U_
UNIT COST TOTAL COST
1.00 2,000,00
01 00170797-00170797 TOT 45.59
DATE: 10/31/9: TIME: 10:54
CONSTRUCTION AND PLANNING !
Date
APPROVALS Permit fir`
Ipspector
POG 1 SPA
APPROVALS Permit
Date
Inspector
1. Temporary Electrical Service or Pole
52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd.
53. Steel Reinforcement
3. Electrical Conduit'Utility-Undrgrnd.
54. Forms
A. 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, ❑ 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 Electrical -T Bar Ceiling
69, POOL/SPA SYSTEI,IS FINAL
19, Rough Heating & Air Conditioning
FIRE DEPT. REQUIREMENT
APPROVALS Permit =4E
20. Rough Factory Fireplace
-
21. Ducts, in Structure.
70, Underground Hydro
22, Ducts, Ventilating ,
71. Product Piping n Gas ❑ Oil
23. Gas'Pipe-Rough & Test
72. Underground Flush
24. Roof Framing -
73. Undergrnd. Storage Tank 0 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. FIXED SYSTEM FINAL
29. Insulation
78. FIRE PREY. FINAL
30. Drywall Nailing
HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat
'
.79. FINAL INSPECTION
32. Electrical Power MeterFinal
80. FOOD CERTIFICATE ISSUED
'
33, Final Electric
Notes:
34, Final Heating & Air Conditioning
35, Final Gas Pipe -Test
r.
36. Hood or Canopy
37, Final Factory Fireplace
'
38. Final Plumbing
39, Water Service -Final
40. Gas Service -Final
41. Solar Domestic -Final.
42. Backflow Preventer,
43. Backflow Irrigation
44. Landscape Irrigation System
45. Sound Attenuation
46. Handicap.Regulations
47. FINAL STRUCTURE & BUILDING
48, FINAL PLANNING
49. Electric Release to Edison
50. Gas Release to Southern California Gas Co
51. CERTIFICATE OF OCCUPANCY
No. Date
-
-
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 earliest opportunity
to avoid unnecessary delay in processing and issuing your building permit. No building permit will be issued
until this verification is received.
1. 1 personally plan to provide the major labor and materials for construction of the pro-
posed property improvement. O Yes ❑ No
2. 1 (have/have not)ye signed an application for a building permit for the
proposed work.
3. 1 have cc
Name _
Address
Phone (
with the following person (firm) to provide the proposed construction:
A. -T' � tyoc-u-4� 11 S
City 'T V_ V* F_ kA N\-
Contractor's Lic. No.
4. 1 plan to provide portions of the work, but I have hired the following person to coordinate,
supervise and provide the major work:
Name
Address
Phone (
City
Contractor's Lic. No.
5. 1 will provide some of the work but I 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 and Safety C e and have completed the above information to the best of my per-
sonal knowledge, IP nce ith this tate law.
Signed: L Date:
r
Name:
(Printed or Typed)
C.D.L. # or S.S. #
754-5273
1 N2 d6
Lot 98
Tr 3722A3qq rr��
026
COSTA MESA BUILDING -SAFETY DEPARTMENT
P. O. BOX 317 COSTA MESA, CALIFORNIA
For Applicant to Fill In Completely
TYPE OR PRINT
BUILDING
1694 Iowa Street
COSTA MESA. CALIFORNIA
FEE RECEIVED
FINANVF QFPT
AP IV IV
BUILDING
For Office Use Only
RECEIPT NO. PERMIT NO.
OWNER
MAIL - -
RECEIVED BY
DATED R`CEIOVED/ DATE 1 LIED
ADDRESS - -
i /�
I J / -Y/l- C1 1 4 W1
TEL'
/
CITY W ORT BEACH NO. MI 6- Z
BUILDING
ADDRESS
ARCHITECT TEL
COSTA MESA. CALIFORNIA
OR ENGINEER NO.
FIRE
ADDRESS
ZONE
TYPE GROU
CONTRACTOR K W KOLL
APPROVED
BY
DATE
ZONING
ADDRESS
ZONE
NO.
OF
USE OF NEW
clrY
R-1
PLANS /Z
BUILDING' W att gar
/ /
STALIC. I 6- ZZ
LHGAL
NO 6 NO. M
OHSCRIPTION
TIpt 930 Tract 37PP
SIZENO. OF BLDG. O
63x100 I
OF LOT NOW ON LOTS
A. P. No.
11On2
USE OF NONE
YARDS
EVES
EXISTING BLDG.
APPROVED
ALLOWED
SETBACK LINE FROM '(CENTER
501 251
LINE ST.)
CENTER OF STREET REAR YARD
FRONT
FT. IN.
SIDE YARD I LEFT 616" I
RIGHT 6161t-
R. SIDE
FT. IN.
DESCRIPTION OF WORK _
L. SIDE
FT. IN
NEW x II ALTERATION I I ADDITION I
REAR
((.
.7 FT. IN,
REPAIR I II MOVING I II DEMOLISH I
APPROVED
BV W.
L. D.
ATE 10-10-60
BUILDING
SIZE 161175 ROOMS 6 STORIES
EXTERIOR WALLSTUCCO IROOFCOVERT g Xood Shingle!
COVERING
USE OF BUILDING AND WORK TO 59,P ' ERFORMED
SINGLE FAMILY ' ESDENCE
and Attached Garage
Plan -EI--
i HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
THE AMOUNT SHOWN UNDER VALUATION IS POR THE
AND STATE THAT THE ABOVE IS CgNRECT AND AGREE TO DOM-
PURPOSE OF
ESTABLISHING A PERMIT PEE ONLY.
PLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING
VALUATION
a �-
BUILDING CONSTR O
SIGNATURE O •/
PERMIT FEE S J
PERMI7TE
S
/
(/
PLAN CHECK S �Q
lam'
AUTHORIZED AGENT
TOTAL FEE