HomeMy WebLinkAbout2019 PHALAROPE CT - Building Permits Applicant to fill in all spaces within heavy border lines and sign all appropriate declarations.
CITY OF COSTA-MESA PE IT NO: TRACT-NO. -LOT NO. •BLDG.NO.' . - - .
•CONSTRUCTION PERMIT '5�� • ?L.;) ' ;
Project Address •y �� C -
6•IJ '
r7-ci/ J /. /�-�C./�-.�/,u� TYPE OF CONSTRUCTION -,
Owner - .... L'. we Phone p/- 0 NEW 0 ADD 0 ALTERATION _ -
❑'REPAIR 0 CONVERSION-0 DEMOLISH ,4 •
/// ❑'OTHER
DESCRIPTION OF WORK - '
' _� — TYPEOFPERMIT - _; ' LDING
Address S / ' , ,(-x " 0 GRADING 0 FOUNDATION 0 STRUCTURAL SIDE YARD
LICENSED CONTRACTOR DECLARATION . 0 TENANT '0 ELECTRICAL%LUMBING" 0 MECHANICA SIDE YARD
I hereby affirm that,) am licensed under provislo> sof Charter 9(com RIGHT •
mencing with section -7000) of Division 3`aaa-I the Business and 0 OTHER
Professions Cotl nd %m license Is in full forcend effect.' . REAR YARD(TO P/L) ' - .
i i� ' PROJECT DESCRIPTION
License�ila�ss7 '•� � Zicen Nq �-�f'Y - PKG.SPACE REQ. - ' ,. PROVIDED . .
Date i ;r'/- Signature / 4121------P)1 Gaa,e,I SQ..FT.' - - - _ ,. __ _ .,
WORKERS'-COMPENSATION DECLARATION OCCUPANCY—CONSTRUCTION TYPE STREET WIDTH PARK FEE$
I hereby affirm that I have a certificate of consent to self-Insure or a • VALUATION ZONE ZONING APPROVED BV - -I DATE '
certificate of Workers' Compensation Insurance, or a certified Copy - - .
of(Sectiy 3800,dLaabp C.)/. /�� // GRADING CU.YDS. - ACRES -SPECIAL CONDITIONS:— ' '
y N O.OP,
- �"�SCC C--.SZ--P.
.. - _ _ -
V Certified-Ctipy Is hereby furnished. / , ' _REMARKS: ' ' - - '
S'-Befed copy is filed with the city Building Division. - • .
EXEMPTION FROM WORKERS' COMPENSATION DECLARATION - - _
(This section need not be completed if the permit is for'one hundred - .•
($100) or less). . . - . -. ._ . - .. - - ..
Certify that In theperformanceof the work for which this permit is
issued, I shall not employ any person In any manner so astobecome :PLUMBING ' , PLAN CHECK • •• - . -ELECTRICAL'_. • PLAN CHECK
subject to the Workers'Compensation Laws of California. UW tLLING GA RMC,E
Date Signature ' - BATHTUBS SHOWERS • - • - - -
NOTICE: If after making this declaration, you should become subject TOILETS • . . ' URINALS • GENERATOR 0-1 KW_1-10 KW -
to the Workers' Compensation provisions of the Labor Code,you must TRANSFORMER
forthwith comply with such provisions or this permit shall be deemed LAVATORIES 12,111.1_8_13E_LAVS . ./- - -ll APPLIANCE - 10-50 KW_50+ KW' - . . ,
revoked. - KIT.SINKS - -- ' 'DISHWASHERS i' •' :r : C'U MOTORS
CONSTRUCTION LENDING AGENCY - - 01 HP -1-10 HP
I hereby affirm that there is a construction lending agency for the per- SERVICE SINKS MPS------- (INC.SOLAR) 10-50 HP 50+AHP' '
formance of the work for which this permit is issued (Section 3097 •' - '
Civ. C.). - - " ' - - FLOOR SINKS - FLOOR DRAINS - FIXTURES- - •- OUTLETS . SWITCHES - -. . --
Lender's Name - ,
Lender's Address - DRINKING FOUNTAINS ' GAS TUBE SIGNS - .- _
OWNER BUILDER DECLARATION INTERCEPTORS.'" ' CLARIFIERS • ' PO LE LIGHTS - _
I'hereby affirm that 1 am exempt from the Contractor's License-Law for - -
the following reason (Section 7031.5 Business and Professions Code: SWIMMING POOL P TRAP- LUNS I NUL I IUN -
Any city or county which requires a permit to construct, alter, - . 'POLES"' - METERED 'SUB - '
improve, demolish or repair any structure, prior to its issuance,also re. WATER SERVICE ALTERATION - - -- PANELS - MAIN - SUB -
quires the applicant for such permit to file a signed statement that he - -
Is licensed pursuant to the provisions of the Contractor's License Law. ... . SERVICE • - -- AMP S
•
((" Ater 9 (commencing with Section 7000) of Division 3 of the GAS SERVICE - OUTLETS
I ess and Professions-Code)-or that he is exempt therefromand the WATER HEATERS BTU'OUTPUT • - - - - - •-
i for the alleged exemption. Any violation of Section 7031.5 by
a, _ applicant for a permit subjects the applicant to a civil penalty SEWER CONNECTIONS _ . - -• • - - •- - - - - - . - - - - ' --
of not more than five hundred dollars ($500): -
❑-I, as owner of the property,or my employees with wages as their SOLAR TANK • COLLECTORS- . ." .-. '
sole compensation, will do the work,and the structure is not intended '_ • -
or offered for sale. (Section 7044, Business and Professions Code: The SOLAR PIPING SYS. -- - - `" ISSUE FEE - -: - - . _
Contractor's License Law does not apply to an owner of a property - ..-r APPLICATION APPROVED BY "' DATE
who builds or improves thereon, and who does such work himself'or 'ISSUE FEE 'Y -
through,his own employees, provided that such improvements are not
Intended or offered for sale. If, however,the building or improvement 'MECHANICAL - PLAN CHECK' - SUMMARY OF FEES -
is sold within one year of completion,the owner will have the burden ;, _
of proving he did not build or Improve for the purpose of sale): - - - - - BUILDING . -
HEATING SYSTEM 0-100,000 BTU , PERMIT $ SMIP $
❑ I, as owner of the property, am exclusively contracting with AND DUCTING - - - - - '• - • .
licensed contractors to construct the project (Section 7044, Business 100,000+ U BTPLAN CHECK $ • PERMIT. -
and Professions Code: The Contractor's License Law does not apply to ISSUANCE $ '
'an owner of property who builds or improves thereon, and who con- REFRIGERATION 0-100,000 BTU PLUMBING - $- (/,' .
tracts from such-projects with a contractor(s) licenned,pursuant to. -SYSTEM - $ _ GRADING ' $ ' - - t
the Contractor's License Law). - 100,000+BTU -- 'PLAN CHECK - •• ' '
al am exempt under Section - • -B.-& P.C.for this BOILERS BTU - - ELECTRICAL- $ 1 '$
reason - PLAN CHECK $ MICROFILM-$ r
SYSTEM REPAIR,ALTERATION ' - . '
Date Owner • TOTAL FEE$ -
I herebycertify that I have read this application and state that the above EXHAUST SYSTEM MULTIPLE - • -MECHANICAL $ ..
Y PP r LESS AD- • ,
informationrdinasd correct( I agree to comply with all city and county PLAN CHECK :$ -VANCE PC $
ordinances antl'sta lays relati to construction,and hereby authorii¢ '
representatives of his Deity' o enter upon the -above- mentioned - -• - - - '��L� '•
propertygnatr for ins tion p -- / // - • Z LJ
---
Signature( A- //��%I) Datid- .- 77-"
FINAL FEE S
Drivers'License or SS � � • ISSUE FEE _
CMF 0865-46 White-Building;Canary-Applicant;Pink-Accounting;Goldenrod-Assessor
r.n 4t .• 414 . i.r ,.1.. . .
CONSTRUCTION AND PLANNING _ POOL'&SPA 1 ' ', ' c ' ,
p Date Inspector Date- . - Inspector
APPROVALS Permit# /J o 18- APPROVALS' i1 . Permit# • .
1. _Temporary Electrical Service or Pole _ . . . ____ - 43. Pool & Equipment Location - -"- _ --- - ' ' '•- '
--2. Soil Pipe-Undrgrn :- - - - _ _ _ 44. Steel Reinforcement " - - -- - - - - -- - - • -• -
3. - Electrical Conduit Utility-Undrgrn - . _. . - -. _ -45: Forms •• - -'-_ -- - - - --
.-4r Electrical Conduit-Undrgrn ___. .- - •- _ -- - - _ - _ - _ -- 46. - Electrical Bonding - `- - -- - - - ' - - - - - - - - -
5. -Steel.Reinforce. - _ - _ +, _47. . Rough Plumbing& Pressure Test -- - - - - - -- - -- - ----
6.- Electrical UFER Grn _ _ - . _ . 48. APPROVALTO.COVER=GUNITE -- - - •
7. ,Footings _ _ . ' 49. Electrical Conduit-Undrgrn` ' '
• -8. -Foundation - -- - ---- - -:- --- _- -- 50.:. -Gas Pipe, ❑Undrgrn,Tesii " -4' '' ' - �• ""
-9. -Water.Pipe-Undrgrn - -- __ n
. ___ _. .. -51.. Backwash Lines P-Tra. - ❑ . d .rn r _ - -
10.- Structural:FloorSystem . -- -. - 52.- APPROVAL TO DECK ---'
-11.- -Property-Sewer Line& House Connection- - - 53. Backwash& Receptor-Final ` .
i-12. --Street Sewer Connection. - - -1- - ` -.L -- - &
• 54.- Heater' Vent=Final; - •
-13. - Rough-Plumbing- _ - - ___ .__ Plumbing System- Final- - - - -- - --- - -
. 14. Rough Electric-Conduit - -- - . . - - - - •-'56. Electrical-Final - - ' ' .. - ' - - .., 15. Rough Electric-Wiring - - - - - ---. '- _ 57. Solar System-Final ' _ , . . . , - . . • - ' - , '-
16.--Rough Heating& AirConditioning- - 1: -:- -- - - - - ---- =b8 Fencing&Access Approval - . •
'- 17.---Ducts;in Structure - -.r,:- ----- - - -- - -- - -: - - - - -- -59.. .APPROVED'FOR'P_LASTERING ., ., .- `
'18.'-Ducts,Ventilating--- - - - - - Z. - • -- -F- --
. 19. Gas Pipe:Rough &Test• r 1.- -- - - - - - - 60.- _POOL/SPA'SYSTEMS FINAL" °: " '
20.; -Roof-Framing -- --- - - - -- - - ---- - - -
21. Roof Sheathing:. _ - `- '-- - - - -- --- .. - - - -- - •'• ,1.., c.. . ..�
_ :
22: Frame and Flashing, NOTES: - - - - -
- - - - - - --- - .. . _ .- -- - - -- .
•
- -
25., Drywall Nailing -- - - - - . -��-c:-,,.. - ! --:- -- -=--- -- - - - -- ._ ._ - ._.-_ _ : -
26.r- Plaster Brown Coat --•' -- :-. -- - - " : -•----.. - -- - --- - -- ...
27: Electrical Power Meter-Final - -- - -- -- --- - - ' -
- ' �'
29.: Final Heating &Air Conditioning- - --- -- - - , -- . ' --
` 30. - Final Gas Pipe-Test---- - --- -- _. . - i- - r - -- - - - -- - - -_ " :
31 Final-Plumbing---- --- - -- . - %2•2! -- I-�%, . . .. I;
32. Water'Service=Final -- - : : - - •^ - - -- - -- - - - - - -- . . - -
{ 33. Gas Service-Final" _ _.-
s
34. Solar Domestic=Final ' '` ' - __ j _ •' .r :rv•a.,..-,r; . . ,
35. Landscape Sprinkling System 1 , .., - -. --
36. Sound Attenuation - - ' '` 1 - '` "
: 37. . Handicap•Regulations - - - --i - - _ - . _ - . ,
38. FINAL STRUCTURE&BUILDING _. _ .. _ __ _ . . _,
"'
39. Special Requirements Completed .. , - - - ' -- - - - - - "' -
140... Electric Release to Edison 1 - . • ...
41. Gas Release to Southern California Gas Co. ' . . '
42. CERTIFICATE OF OCCUPANCY I • - -- -- - -- - - - - -
v
No Date V
PROJECT ADDRESS: UNIT:
OWNER'S NAME: 2019 PHALAROPE 'CT CITY OF COSTA MESA — BUILDING PERMIT PERM NO: B 065575
agDREss: SECKEL, KARL W
SECKEL, CLAIRE D PERMIT NO: B 065575 PLAN CHECK NO: 00054-94 S GOVT: N SUPP: N
2019 PHALAROPE CT
COSTA MESA,CA 92626 CONSTRUCTION TYPE: 5—N C,LLA RMIT TYPE: STR PURPOSE: ALT
842-9122
AflCNIEN DRESS
ADOflESS:
I
REG.NO.: JOB DESCRIPTION : T/O 6 REROOF W/LT WT TILE ICB0#4660 SQFT: 6, 500
: UNIT: n
• PERMITTEE: CLAIM VALUE: 6, 500 . 00 CALL—VALUE: 6, 500 . 00 GROUP OCC: R-3 /M-1
onus: ACTION FIRST ROOF CARE ( 714 ) 841-7663
18352 GOTHARD ST q dp COMMENTS• SMOKE DETECTORS REQUIRED PER 91UBC REROOF 2850SF RESID W/LT TILE
' �ON �Eh4wCH Cr�' 6n�ok2T ********4* **� ************eek ***********�Fr�r�rfr*************�ifry�t(}��i��(�, i�r[, i�(E�Ef**x iii��F iiiFFE
�k 7000)otD CONTRACT ession a um 1 am licensed uncle r ch er 9(commencing with Section V I Y F V I t V��/
70001 01 Division 3 T the Business and Professions Code,and myaH license d in full force and effect. Z O N I N G R E Q U I R E M E N T S
CITY LIC.: STATE LIC.: CLASS: SETBACKS ,s• .
045135 50290�0�/��/��)--'y�C-39 Q �,5...���pa.,.,,�� ,�.
Date:_S' • S cf /� ISherebyalli 7aMAIN BUILDING ACCESSORY EAR: '��A—+—A---
WORKENS'COMPENSATION DECLARATION: I affirm that l ve a certificate of consento sell-insure or a certificate of Workers' FRNT: FT IN REAR: FT IN FRNT; FT IN REAR: FT IN •
Compensation Insurance.or a certified copy thereof(Section 3800.Lab.C). LEFT: FT IN AGHT: FT IN LEFT: FT IN .RGHT: FT IN
POLICY NO.: 1042000-93 EXP.DATE: 09/01 /94
COMPANY: STATE FUND PARKING REQ: PROV: PARCEL: 13953213 ZNE: REF NO:
Certified copy is hereby furnished. Certified copy is lit with city Building Division. PLANNING NOTES>
>
S
Dale: / . /7 Applicant. 5 / ************'**1E****************************************************************
EXEMPTION FROM WORKERS'COMPENSATION DECLARATION: (This section need not be complete if Me permit is for one h u Bred(5100)or less). D E V E• L O P MEN T SERVICES REQUIREMENTS
1 certify that in the performance of the work for which this permit is issued.I shag not employ any person in any manner so as to become
subject to the Workers'Compensation Laws of California.
Date: Signature- ZONING APPROVED BY DATE:
NOTICE:II.after making this declaration,you should become subject to the Workers'Compensation provisions of the Labor BUILDING APPROVED BY
Code.you must forthwith comply with such provisions or this permit shall be deemed revoked. DATE:
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for APPLICATION:ISSUED B Y: \ ( 1.�
which this permit is issued(Section 3097.Civ.CI. DATE: ** ie
LENDER: *******************************************************************************
ADDRESS: TILE WEIGHS 7PSF MAX LEGALIZATION:N F E E SUMMARY STRUCTURAL SEGMENT:Y
OWNER BUILDER DECLARATION: I hereby affirm that l am exempt from the Contractors State License Law for the following reason BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE- SMIP/RES GRADING
(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 lite a signed statement That he/she is licensed PERMIT 90 .00 . 65
pursuant to the provisions of the Contractors'State License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business SMIP/NON—R E S
and Professions Code)or that he/she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by PLAN 58 . 50
'
any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars(55006
ISSUE FEE -
I. as owner of the property or my employees with wages as their sole compensation, will do the work, and the BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL . PAID •
DUE
❑ structure is not intended or offered for sale(Section 7044,Business and Professional Code: The Contractors'Slate License Law TOTALS————> 90 . 65 0 . 00 58 . 50 14 9 . 15 149 . 15 . 00
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 REVENUE DIVISION TOTALS--> COLLECTED: 149 . 15 OVER/SHORT: 00
tor;he purpose of sale). BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT," GRADING PLAN—CHECK
I,as owner of the property.am exclusively contracting with licensed contractors to construct the project(Section 7044.Business 90 . 00 . 65 58 . 50
❑ and Professions Code: The Contractors'State License Law does not apply loan owner of property who builds or improves thereon
and who contracts for such projects with a contractor(s)license pursuant to the Contractors'State License Law).I am aware
that proof of their Worker's Compensation insurance should be provided to me. *'****'******************************'******************'***"***********************
❑ I am exempt under Section: B.A P.C. INDIVIDUAL F E E BREAKDOWN
tor his reason: TYPE QTY DESCRIPTION UNIT COST TOTAL COST
Date: Owner:
do hereby cemly that lam aware of aro understand the requirements of Califorola Heallhand Safety Code Sections 25505.25533.and SFR 6500 REROOF BY VALUE RESIDENTIAL NOZONE 1 . 00 - 6, 500 . 00
25534 and that I or any future building occupant wilVwill not(circle one)need to comply with said state codes and the requirements for a END OF FEES
permit for construction or modification from the Au Duality Management District,Residential construction applications are exempt from r
these provisions.
Date: Applicant:
n •.
I hereby certify that I have read this application and state that the a information is correct.I agree to comply with all city and county
ordinances and state laws relating to building construction and hereby hurl epresentatives of this city to enter upon the above-mentioned
property for inspection purposes.
/
IDate- 1 • 5 • Y Signature 01 0015125:.-00153257 TOT 149.15
Driver's License or Social Security 4: DATE: D3/O3/94 TIME: 11:55
164146 White—Building:Green—Code Enforcement:Canary—Applicant:Pink—Revenue;Goldenrod—Assessor
•
CONSreiiCTivNANDPLANNING I � 1 POC SPA 1
APPROVALS Pcrmit s!, D.,te Inspector I APPROVALS Permit _ Dn., :r,p.:ctor
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1, Tempn'dry E at:Rica: S:" c. o' Pore I52. Pca'' & �^
Equ'prnt Locator, '
1 2, So : P u. i:iirp-^r1 - - - 1 53. St^ri 3.,„(incl rnent
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I 'S Rcs•th E'e!.•.:ra, T R'r Ce., -c 1 O° P00.../SPA EYSTE:,-.S I'NAL
19 Rough ' cuing R. Ai Cm"u t uning 11 FIRE DEPT. REOLIIREV,ENI '
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OWNER PEMBA SURD HERS INC. PATE z 4-00
JOB ADDRESS 2019 Phalarope Court BUILDING PERMIT NO. 25236
GENERAL CONTRACTOR Sane DESCRIPTION OF WORK Res. w/att. garage
AP No. LOT 66 TRACT 5493 FIRE ZONE VALUE $ 27,53 .00
I' FCTIONS ^Signature Date GROUP I&J TYPE V ZONE R-1
st `L e- 7,01" . PERMITS ISSUED
Gas SUBCONTRACTOR I Date I Number I Signature
Water/ .f/ eigrar/��ei/1" Plus b'ig i
Rough Plumbing i ' y
d i� / /QQ
Prop. Swr. Line 'fiouse Con. ' <‹/t _ je _ ;'
•�
Sprinkling System /
Miscellaneous
Rough Heating and Air Conditioning '„ /4,-7.
•
Temporary Service or Pole
Underground ❑ Power ❑ ,
Rough Wiring y_/.,:e3 Heating and Vent.% / _
Trenches i® Forms 21 Steel Reid. 0 ASS 3/-46 r�tvrtia�i/ 62.4/(KAYLA/ ...9-44‘ SL447.5--
Floor
r9S
Floor System,d(&d dfl y%46
Bond Beam 0 Steel Reinforce 0
Sheathing y.$',L "'Y /CG •
Frame and Flashing / -/,
Lathing — In vas Out ® 1Pf d_ / 51464%
Plaster, Brown Coat r'7+� h7- ST�y/`f
S'- -^[ural, Final ((ff Elf�tric /
1 ng, Vent., Refrig. and A.C., Final G/l?-f/� li1 D d/f �— 0'.S-rte ago4
Plumbing, Final and Gas Test a- ,o/��
Electric, Final / G(0 6 F.
Buildine. Final 40-, /_>P/__/2
Lot66549325236 CITY OF MTh MESA
COSTA MESA BUILDING-SAFETY DEPARTMENT FEB 2 1966
P.O.BOX 317 COSTA MESA.CALIFORNIA
For Applicant to Fill In Completely APPLI A O F f f 1T
TYPE OR PRINT
BUILDING For Office Use Only
ADDRESS 2019 Phalarope Court
RECEIPT NO. G,}vIP2RM�T2:2;2436°.COSTA MESA, CALIFORNIA L
R8C8 DBY DATE RECEIVED
OWNER Pemba SubdividersG-
, Inc. lb - < ng
IUEDMAIL /I
BUILDING , 2O/9 1 CIA /J�_ ( /S- /
ADDRESS 2850 Mesa Verde DriveFIRE
ADDRESS 'Y 7 �/"/�Z[X,CZJL(/(ff+lQ�1T.-6JW/`
TE t ZONE TYPE GROUP Eby
c,T. Costa Mesa, Calif, NDL549-039 � iJ
APPROVED
AR" "TECT
WEER Kaltenbach N j647-804E BY DATE
DRESS 1823 E. 17th St,SantaAna ZONING
AD ))
ZONE NO.OP BUSH OFNEW(14449/4-iia- ../
CONTRACTOR Pemba Subdividers, Inc, R i I PLANE D/2 I /UILDIN-�/,
LEGAL ✓ / la b d.��.g
ADDRESS 2850 Mesa Verde Drive DHSCMPTMN "'LLL
CITY- Costa Mesa, Calif.
A.P.NO. 7c73
NOTE: NO CAVE OVERHANG SHALL BE LESS THAN
STA
LIC.No. 187318 TNEL 549-0395 30^TO SIDE a REAR P.L.
EAVES
OF LOT 70 x 105 1 NO.OP BUMS. 0
NOW ON LOT ALLOWED (U.B.C.REQUIREMENT)
USE OF Single FamilyResidence YARDS APPROVED YARDS APPROVED
EXISTING BLDG. g _ MAIN BUILDING ACCESSORY BUILDING
(FROM C/L STREET
SETBACK LINE FROM 51 • • 26-75 FRONT <7 FT. ?Id W l FT.
CENTER OF STREET REAR YARD /
SIDE YARD I LEFT ) 3 I RIGHT 6 R.SIDE -4 FT. FT.
DESCRIPTION OF WORK L.SIDE 1 0/PT. Fr.
NE __ ALTERATION _ ADDITION REAE�6.7)Ff. FT.
DISTANCE BET. BET.MAIN e
REPAIR MOVING _DEMOLISH MAIN SLOGS. ACCESS.SLOGS.
BUILDING NO.OF
VAR.# DATE
SIZE 2081 ROOMS 11 STORIES 2 C.U.P.# ` APPROVED
EXTERIOR WALK ROOF Shingles & APPROV:I.` / /
COVERING atuCCOl COVERING shakes BY I LSM DATE /- ��O b
USE OF BUILDING AND WORK TO BE PERFORMED
09/SQ.FT. 14/d 1,
7• r i
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE S
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM. PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. G
PLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING VALUATION (�A �.� m
BUILDING CONSTRUCTION. a.. N
SIGNATURE OF PERMIT FEE S_ A-) , ,y
PERMITTEE /7P a, �rE" Y/ �j�/l !� F'
$(2/,`/J� 3 7 ,J
AUTHORIZED AG l y 7'7 1'
, TOTAL FEE $ 1 U
V