HomeMy WebLinkAbout951 POST RD - Building PermitsAPPLICATION FOR A BUILDING PERMIT
BUILDING PERMIT NO. Eieariwi
Trat[ Blotk Lot � Parmit No.
Builtling //� O� � �� /�� Plumbin9 .
Atltlress J /O �rmll No.
Cross � �� Mechaniwl
p,rpa �O � $trcet D — t Permit No.
/.>
Owner �� /J A ��,� Typo of ProjecL ew ❑ Alter ❑ Atltlltion
•�l
Arltlress / � �A ❑ epair ❑ Convert ❑ Demo ❑ OccuOancy Pmt.
Clty G S'fA M ES/� Z�p / GOG.�i hone 6 �� A• • Sup. Dlst./
Insp. ArBa
Archilect/ Z pa SPI. Pmt. No.
O�i9ner pr'Li nse No.
' C Se backs P/L Front C/L SL Straet WiU[b
Aaaress
Var 5 Lefi Righ edr
ptY Zlp Phone
ava rol. �9 . .
r En9lneer �icenu No.
� Park�ng Spatez eq reE rov e overe
y Atltlress
m Struct No. ot No. ol
m q(y Zip Phone Hel9ht Stories Family
� LICENSED CONTRACTOR'S DECLARATION Park Foes Ves Fee
�° Requlretl No C.T. Receipt
m 1 hereby affirm that 1 am licensatl untler provisions of Chepter 9
(commantinp with SectiOn 7000 of Division 3 ot the Business antl
« Protessions Cotle, and my license is in full force and effect). 2oning Approvetl By: Datc
2� Licanse Clae License Numtr¢r
T Dete Contractor Mizc.
E Atldress Aoposce Use O�
of Struc[ure
�y City antl Zip_ Phone
v� CONSTRUCTION LENDING AGENCV '
� 1 horoby aftirm that thera is a consnuction landing agency tor the
a performance ot the work tor which 2his permit is issaetl (Sec. 3097, �CO' � Type Cotle
' Civ. CJ. Class Const. voar
y Londor's Name US OCCUPANCV SIZE SQ. FT.
C Lentlar's AOtlress
'� OWNER-BUILDER DECLARATION
� I har by atfirm thet I am exemp[ trom the Conbactor's Licen9e Law 1�
� for e following reeson:
� I, as owncr of [he Froperty, or my employeas with wages as their 2.
C mle compemation, will do ffie work, and ihe s[rucxure is not
t intentletl or ofinretl for ule. �
�' 3.
� ❑ I, as owner ot the property, am ezclusively cOniracting wi[h
licensetl convac[org t0 consV uct the projacL ,
r ❑ I am ezompt unAer $ac. , B&PC for this reawn 4'
d
a Date Owner_ Totai ValuaHon
E WORKERS'COMPENSA710N DECLARATION
� I hereby efii�m that I hava e certificete of consent to self-insure, Encroachment Permit ReqWretl ❑ Ves ❑ No
or n cortifiwia of Workeri Compensation Insuranca, or a tartitiatl
C copV thereof, Gratling �mL Gratling
� Policy No Company Requlretl ❑ Ves ❑ N Pmt. NO.
�n ❑ Certitietl copy is horeby tumished. Rough GraEln9
d ❑ Cnrtlfiatl copy is tiled with Orange County, EMA. •
a Approvetl by: Date
Date Applicant
CERTIFICATE OF EXEMPTION
FROM WORKERS'COMPENSATIONINSURANCE
(This section naetl noi bo complotetl if permi[ is for $/00 or lessl.
I certify that in the parformance af Ihe work for which ffiis permit is
issued, 1 shell not employ eny person in any manner o as to�become
subject to the Worke�s' Compensati Laws f Calito e. PERMIT FEE$
oei �-/3 - Srl APPlican[ ��i(/��L/1-� L. n �.
NOTICE TO APPLICANT: It, after making this Certificate of Structural 5 Plan C eck y
ExempUon, you should Aecome sublact to the Workeri Compensation
prOvisiOns Ot tho Labor Cotle, you must torthwith cOmply with such Elettri<al SPeCi I
provisions or this parmi[ ehnll ba tleometl revoked. § Inv¢5 . S
1 CERTIFV THAT 1 HAVE READ THIS APPLICATION AND STATE
THAT THE A80VE INFOPMATION IS CORFECT. I AGREE TO P�umbinq S
COMPLV WITH ALL COUNTY ORDINANCES AND STATE LAWS .
RELATING TO BUILDING CONSTRUCTION, AND HEREBV AUTH- Mechanital S �
ORIZE REPRESENTATIVES OF THIS COUNTV TO ENTER UPON
POSE87BOVEw���'O V FOR 1��! ION PUR. pre-GraGe 5
� Insoactlon
$i�3�e oi Applicant or Agent Date �/ Pre-GraUe S Pe�mit s
Rec. No. issue
%2i tiiili2 /� S d(/Oi E
Print ApplieenYs/AgonYs Neme
Plan ISsuanc¢
All spateS Witbin thi5 b0% must be Chetk By: Approvetl:
CMF 0335-46 (BU-28) rev. 6/80
CITY OF CUSTA MESA
CAIJFORNIA 42826 P.O. BOX 1200
FROM TME OFFICE OF THE DIRECTOR OF BUILDIN6 SAFETV
Project Address 9J�� J C7 �� Y I Q"�drS� I�[F� Q�o`�
Project Name
Raners Name G Q C! l£
Owners Address �yCS �/ p,S� q �OSIT� /'(F S� [ a2�o a
Ownecs Belephone ��y �i�C ' ��I (o
��„�t � sr ��z
�
Zype � — /V
City Use Chly
i f�IG12Gp� /'l_�VU!£ as Owner, C.errtrae�or, Ac�enh-(strike out all
exc'ept one) do hereby attest that e�loynent of any peison, or persons, is not
anticipated at the tune of seeking the above-referenced pecmit. In the event that
any person, or persons, are e�loyed under the prwisions of this permit, I shall
im�diately cause a valid Certificate of Worlanens Cw�q�ensation to be filed with the
Costa Mesa Building Division.
I agree to defend at my a,m mst, arcl to indemnify and hold harmless, the City,
its officers, agents and/or �loyees, fran and against, arry and all liability,
damage, costs, losses, claims and expenses, howscever caused, resulting directly
or indirectly fran, or connected with the improvement under this pernut.
I further state that I have read and fully imderstard the implications and re-
sponsibilities of the above statements, and will crntply with all provisions of the
Contractors State License Iaw found under the Business and Professions Code,
Division 3, Chapter 9, of the State of California.
-��LYIQf� 1'l �Qi1���
Print Name
G���,��� .����o `�'�3' ��
Signature ' � Date
CMF 0777-46
CITY OF COSTA MESA
CALIFORNIA 92626 P.O. BOX 1200
FROM THE OFPICE OF THE DIRECTOR OF BUIIDINO SAFETV
Project Address % s/ 7 OS'� ��. �� � I�rmi t#
Project Name
O�mers Name
c��� `ij'P2
�r�� 1.CYiL!/ ��i� .t ltc..i � � ` V ' J
Owners Address ��S/ %�D�S� /(�lJ � �, /Lr. City Use Only
,
O.mezs Telephone �e�`�(�' ��6
Z�,�������,�-('� as Owner, Contractor, Agent (strike out all
except one) do hereby attest that e�loyment of any person, or persons, is not
anticipated at the time of seelcing the above-referenced permit. In the event that
any person, or pexsons, are e�rg>loyed under the provisions of this permit, I shall
imrediately cause a valid Certificate of Worlanens Cortg�ensation to be filed with the
Costa Mesa Building Division.
I agree to defend at my own oost, ard to indemnify arcl hold harmless, the City,
its officers, agents and/or e�loyees, frcm ard against, any and all liability,
damage, costs, losses, claims and e�cpenses,'howscever caused, resulting directly
or indirectly fran, or connected with the improvement under this permit.
I further state that I have read and fully imderstand the implications and re-
sponsibilities of the above statements, and will crn�ply with all provisions of the
Contractors State License Iaw found under the Business and Professions Code,
Division 3, Chapter 9, of the State of California.
s�:c�A� � iJ/! .S-,d/�e� c
Print Name
(/L.��s/t,tu�/ /!i! G�fJt?-c.p
Signature
CMF 0777-46
� �
L� te
ApPlleant to.l:ll in all
CITY OF COSTA MESA
CONSTRUCTION PE
Addrea C) �/ �o<T �.
ArchlEng. License No.
Address
Contractor �, Phone
Addres�
within neavy poraer Ilnes anC sign all aoorooriate Geclarations.
TRACT NO. LOT NO. BLDG. NO.
1 hereby affirm that I am Iicansetl untler provisions of Char[er 9(com-
mencln9 �✓�th section 7000) ot Divislon 3 0( tne Buslnest antl
Professions Cotla, anU my Iicense is in full tor<e ana attect.
�icense Class �icense No.
Date SlgnaWre
WORKERS' COMPENSATION DECLARATION
I h!r¢by atfirm that I have d C¢rtlfiCate of consent to self-insura Or a
certifiwte of Workers' Compen5ation Insurance, or a certifietl copy
thereof (Sectlon 3800, lab. C.).
Policy No. Company
❑ CertHletl copy is hereby fumishetl. .
❑ Cerilfletl copy Is flleC with the city Bulltling Division.
EXEMPTION FROM WORKERS' COMPENSATION DECLARATION
(This 5ection neetl not be tompletetl if the permit is for one huntlretl
(E300� or le5s). '
I ttrt fy that in the performance of [he work for which this permit is
issuad, I shall not emPloy any person in any manner so as to become
subje<t t e Wor ers Compensatio�n yLaws ot Call� ni
Date Slgnatura lG,( ��(
NOTICE: It af er makin9 �nls tleclaraUon, you shoultl become zubject
to the Workers' Compen5ation provi5lons Of the Labor Cotle, you must
tor[hwith COmply with sutb Provi51on5 or this permit snall be tleemetl
revoketl.
CONSTRUGTION LENDING AGENCV
I n¢r¢by dtftrm [M1at [her0 IS a COnStrUction Ientling agency (or the per-
formance ot the work lor whicn lhis permi( is i5suetl (Settion 309]
Civ. C.�.
LenAer's Name
LentleYs Atltlres5
or coun[y wnicn tequires a
Is litensetl pu�suant to llt¢ provisloni of [n¢ Con[raC[Or's LiGense Law
(Chapter 9(commencing with Settion 7000) o! Division 3 of [be
Busines5 antl Prdessions Cotle) or [hat be Is ezempt therefrom antl the
Oasis for the allegetl exemplion. Any violation ot Section ]031.5 by
any applicant to� a permit Subl¢Cts [h2 applicant t0 a civil penalty
of no[ mor¢ thdn Iiv¢ huntl�Etl Gollars (E500).
❑ I, as owner of the property, or my employees witn wages as lheir
sole mmpensation, wlll tlo the wo�k, antl lhe SGuctur¢ is not intentletl
Conirdtlor'S LICe05a Ldw tloe5 no[ dppty [O an owne! o! a proper[y
who bulltls or improves ther¢On, antl who tloe5 Such work himself or
throu9h his own employees, provldetl that such improvemenls are nol
intentletl or ofl¢retl lor sale. I1, howev¢r, th¢ bullding o� improvement
is soltl within one year ol compietion, the owner will nave Ihe burtlen
oi proving ne tlitl nat builtl or improve for the purpose of sale).
❑ I, as owner of the property, am exclusively con[ratting with
Iicensetl <ontractors to construct tne prolec[ (Section 7044, Business
antl Grofe55ion5 Cotle: The Contractor'S License Law tloes not apply to
an owner of prop¢rty who builtls Or Improves therEon, antl who Con-
t�aG[s from SucM1 p�Oj¢Cl5 with a contrattor(s) licesnetl pur5uant [O
the ConVactor•5 License Law).
❑ 1 am exempt untler SeCtiOn - B. & P. C. fOr (his
reason
Date Owner
I hereby Certify lhat I bave reatl this applicatlon antl state tM1at tM1e above
informatiOn I5 wrrecL I aq�ee to comply with all city antl county
or0lnances and state laws relating to conztruction, antl hereby authorize
representativ¢5 of thiz Clly f0 entGt upon Ihe abOve mentionetl
Tr-V�LPF�OF CONSTRUCTION
LTrvEW ❑ ADD ❑ ALTERATION
❑ REPAIR ❑ CONVERSION ❑DEMOLISH
❑ OTHER
DESCRIPTION OF WORK
TVPE OF PERMIT
❑ GRADING ❑ FOUNDATION ❑ STRUCTURAL
❑ TENANT ❑ ELECTRICAL ❑PIVMBING ❑MECHAN
❑ OTHER
PROJECT DESCRIPTION .
54. FT.
OCCUPANCV_CONSTRUCTIONTVPE
'VALUATION 20NE
GRADINGCV.VDS. ACRES
REMARKS:
PLUMBING PLAN CHECK
BATHTUBS SHOWERS
LAVATORIES DOUBLE LAVS
KIT.SINKS - OISHWASHERS
SERVICESINKS SUMPS
FLOOR SINKS FLOOR DRAINS
ORINKING FOVNTAINS
INTERCEPTORS CLARIFIERS
SWIMMINGPOOL PTRAP "
WATER SERVICE ALTERATION
GASSERVICE OUTLETS
WATER HEATERS BTU OVTPUT �
SEWER CONNECTIONS �
SOLAR TANK COLLECTORS
SOLAR PIPING SYS.
ISSUE FEE
MECHANICAL PLAN CHECK
HEATINGSYSTEM 0-100,000BTU_
AND DUCTING 100,000 + BTV _
REFRIGERATION 0�300,000 BTU_
SYSTEM 100,000 + BTU _
BOILERS BTU
SVSTEM REPAIR,ALTERATION
EXHAUSTSYSTEM MVLTIPLE
property fo�i�eStlMn pprpqej�..�" Z
Siqnature ��� �✓� E� Date�L
Drivers' License or 55 �SSUE FEE
CMF 0865-46 White-Bulltling; Canary-Appliwn[: Pink-Accountin9; Goltlenrotl-Assessor
ZONE
REAR VARD (TO
PKG. SPACE REQ.
` . . ^ � �.
IING REGULATIONS
PLNTGp. RUEFL. $
PROPE�RT�YNLI NE
PROVIDED �
� PAftK FEE 8
ZON I NG APPRO V ED B V
SPECIAL CONDITIONS:
ELECTRICAL PLAN CHECK
GENERATOR 0-1 KW_ 1-30 KW _
TRANSFORMER
APPLIANCE 30-SOKW_SO+KW_
MOTORS 0-1 HP_I-30 HP _
(INC. $OLAR) 30-50 HP 50 a HP _
FIXTURES OUTLETS SWITCHES
GFS TUBE SIGNS
POLE LIGHTS '
SERVIGE
ISSUE FEE
PLICATI ON
MAIN SUB
�iM AMP
SUMMARV OF FEES
BUILpING —
PERMIT S SMIP b_
PIAN CHECK E PERMIT
ISSUANCE $—
PLVMBING E
G(3ADING S—
PLAN CHECK E �
ELECTRICAL S
S—
PLAN CHECK g MICROFILM $ _
MECHANICAL §� TOTALFEE$_
LE55 AD-
PLANCHECK S VANCEGC S__
FINAL FEE S�.
CONSTRUCTION AND PLANNING POOL & SPA +
APPROVALS Permit # Date � Inspector qppROVALS � Permit # ��e Inspector
1. Temporary Electrical Service or Pole 43. Pool & Equipment Location
Soil ipe-Undrgrn 44. Steel Reinforcement
3. Electrical Conduit Utility-Undrgrn 45. Forms . -
4. Electrical Conduit-Undrgrn ' 46. Electrical Bonding
. tee ein orce 47. Fou h Plumbin & Pressure Test
6. Electrical UFER Grn 48. APPROVALTO COVER-GUNITE �
7. Footings 49. Electrical Conduit-Undr rn
8. Foundation 50. Gas Pipe, � Undr rn, Test
9. Water Pipe-Undrgrn 51. Backwash Lines P-Tra ❑ ndr rn
10. Structural Floor System 52. APPROVAL TO DECK
11. Property Sewer Line & House Connection � 53. Backwash & Rece tor-Final
. 12. Street Sewer Connection 54. Heater & Vent-Final �
13. � Rough Plumbing '
14. Rough ElectricConduit - �56. - Electrical-Final �
15. Rough Electric-Wiring 57. Solar System-Final -
16. Rough Heating & Air Conditioning • encing & Access Approval
17. Ducts, in Structure • APPROVED FOR PLASTERING �
18. Ducts, Ventilating ' � ,
19. Gas Pipe-Rough & Test 60. POOL/SPA SYSTEMS F INAL
20. Roof Framing
21. Roof Sheathin �
. 22. Frame and Flashin NOTES:
23. Insulation
24. lathing & Sidi�g
25. Drywall Nailing
26. Plaster Brown Coat
27. � Electrical Power Meter-Final
28. Final Electric �0
29. Final Heating & Air Conditioning /d' YfT LEO
30. Final Gas Pipe-Test
. 37. Final Plumbing
32. Water Service-Final
33. Gas Service-Final
34. Solar pomestic-Final
35. Landsca e S rinklin S stem
36. Sound Attenuation
37. Handicap Regulations
38. FINAL STRUCTURE & BUILDING
39. Special Requirements Completed �
40. Electric Release to Edison
41. Gas Release to $outhern California Gas Co.
42. CERTIFICATE OF OCCUPANCY
No Date
OWNER TlJEI,COME HOMES DATE 5-18-56
J08ADDRESS 9Sl Post Road BUILDING PERMIT NO. .3032
GENERALCONTRACTOR Welcome HAmes VALUE $ 9,760•��
LOT 2(y BLOCK TRACT 2896 Sin�le Res. w�att �ar
GROUP I Rt J TVPE V ZONE +�4 FIRE DISTRICT 3O%Z
PERMIT9ISSUED
INSPECTIONS DATE SUBCONTRACTOR
—���'��.,,., DATE NUMBER
Footina Trench t/�.�lJ Ur RJ' S a
and Grade to GarapeYlG I. 8�
" Le�At7—L�
r
Heating, Final Y�1 E 5 �' l- 7/%'Lr' v�'V�l�t�tr !:/.( 6— /S - Sb .S/� /�3 �
Sewer House Sewer, St. �� ���1 �y�-�� � ��_�("�, �j �'� � .�
Septic Tank or Cesspool � �
Lathing, In Out x ��� r} a` �^ �' �C�
Plasterin9 �/3" � •
Plumbing,Fin�al,FixturesComplete%Y/L°5_ -a./'j' ,
Plumhina. Fin,al GasTest � -� ii7��J -r%�-.57 \ � �iior'• :��� / �
Wiring,Final f �S �957VP
Occupancy �� �aa�-s�
FORM 210 3M 10-vi
sa Bnilding Department PLICATION OR PERIVIIT
P.O.Box3�� 3�'� BUIL ING '
�OSTA MESA, CAIIFORNIA
FOR OFFICE USE ONLY
'OR APPLICANT TO FILL IN Receipt No. Permit No.
Bullding
Address 9`J 1 Pos t�oe3 �U -3 �
Costa Mesa, California Received/�y Dat6e Rec'd. /Date Issuerd/
Nearest �j /c/ ��p is � IJ��� J 6
CrossSt. bilbt0 Building
Add ress
owner Yleloors Eomes� Zac. CostaMesa,California �
Mail �2g tyestim.nster Ave.
Address , Nearest
Tel. Cross St.
Cit ti�esttninster No.WBIR. 5%1]. Zone No.of T pe Grou�}�v
Y I Plans I Y �!1
Arohitect or Lic, �
Engineer No. Approved
b Date
Address CORRECTIONS
„ City Lic
Contrector�e 1C OI�B II07te 5 T No. 8
address �8 We�t�!snster 9ve.,
Legal Lot �
Description I No. 2�} I Block � 7ract2�G
(Attach Metesand Bounds)
No. of Bldgs
Size of Lot 57X1o5 Now on Lot None �
l�seof I Na.of I No.of • �� , y.� 70
Existing Bldg. NOile Familles Rooma
Setback Line from Rear Yard . � � � f' P �
CenterofStreet 5� Ft. SideVard � Ft. �r– ---�_„ 4i ', y
DESCRIPTION OF WORH . ._ �
, .,
� � V I�_:
New X I Alteration I Addition I
Repair I I Moving � I Demolish I �"" --
�/: �.-... _
Buildin9 No. of � � t.+,' ".'� �
size 2r7�}% Rooms 6 stories 1 "' �- •• •._. �_�
Exterior Wall Roof —
Covering StuOc• I Covering YYopd t�PPR�V�..S
Use of New �, Foundatlon Lacatfon Inspector � Date
auiiding „in�le familY residence and Forms,materiais,
tvro oar garage attached, under-Pinniny
Frame: Fire Stops,
Bracing, Bolts
I hereby acknowledge that I have read this Application
and state that the above is correct and agree to comply Lath. Int.
with all City Ordinances and State L.aws regulating —
building construction. Lath. Ext.
Signature
Permittee Plaster, Int.
Authorized Agt. laster, Ext.
Valuatlon'��'�'�"'•`'`� PermitFee$ MasonryReiniorced
$ �%/ � Q� Tota�Check $ /j� — gond Beam
� � Fee $ � � I FINAL
ir
PLOT PLAN
Show locatlon and distanees irom
property Itne and between bulldinga
.,",Y 18-56P�n�a ''37� r��:�•:�:.i6."1
.... , . � � cl.,
II�,. . ., , �_ ' _
�' �. �,�.� � �ol.�
. o. �
:v. . �..._ �._. .
_' � _(
CV� =`�.
;, 1n
J _ O�'
1 . S; : .
L` )�. �� �.� J .�
�� � � . �Zn•a . 1 . .
•. . . - ' . � �. �
T
OWNER
951 Post Road
DATE
Vo. =14T-43S-28 Lot 24 TRACT 2896 FIRE ZONE VAWE
INSPECTIONS
SOIL
GAS
W ATER
ROUGM PWMBING
PROP. SWR. LINE � HOUSE CON.
SPRINKLING SYSTEM
MISCELLANEOUS
ROUGH MEATING ANO AIN CONOITI
TEMPORRRY SERVICE OR POLE
lINOERGR0UN0 � POWER �
� ROUGM WIRING
p TRENCHES FORMS STE
� FLOOR SYSTEM
� BOND BEAM � STEEL REINF(
�ri SNEATMING
� FRAME NNO FLASHING
roLRTHING — IN �J OUT �J
,� PLASTER, BROWN COAT
a STRUCTURqL, FINRL
NEATING, VENT., REFRIG. AN� �.
PLUM0ING. FINAL AN� GRS TEST
ELECTRIC, FINAL
BUILDING. FINAL
INF.
SUBCONTRACTOR��
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�MESA BUILDING-SAFETY DEPARTMENT
V.O. BOX 1200 COS7A MESA, CALIFORNIA 92626
For Applicant to Fill in Completely — Use Ink Only
BVI�DING�__, � � � � , .,� � �_.
MAI LI NG
ADDRE55
C7
BRANCH
ADDRESS
ARCHITECT
TEL.
NO..
CONTRACTOR � C/ {�Lts
ADDRESS
TEL.
CITV NO.
STATE CITV
LIC. NO. IIC. NO.
OF LOT� ^ I� 4% NO.OF BLDGS.
NOW ON LOT
VSE OF
EXISTING BLOG. 8
Separate permits are required for
electric, plumbing and heating work.
USE OF BUILDING AN� WORK TO BE PERFORMED
,�0772 .4/13/81 -x 84.76 TL
APPLICATIO1Va�OR STRUCTURAL RERMIT �
3ECEIVED PERMIT� � /
v z
A.P. No. iu i_�� �— a�3
UNIT OR
SPACE NO.
TR.NO^. LOT BLK.
Y . L�
NEW ADD ALTER REPAIR MOVING DEMOLISH
OWNE0. d S .
VALVE � �
USE �jr g}� � E —
ZONE TYPE�V� �GROUP R ��
APPROVED�'A ❑GTF ����_7.
0.V
U8r 'ro c�c E
APPROVEDSETBACKS
%
PLANNING ACTION
� 5 -i''�- � ,-�
herah't- �
DATE
APPROVED
1 hareby acknowletlga that I have reatl this application and stete
that the above information is correct and agrea to eomply with
all laws regulatln8 building construction, antl I shall not employ
any Oerson In violation ot the workman's compensation laws of
Ma Stata of California. n C
1 hereby certify that I am properly licansatl es a conttactor under `J SQ. FT. O �
the State of California Business antl Professions Code, Division 3, THE AMOVNTSHOWN UNDER VALUATION
Chapter 9, and that such licenses are in full force antl etfact, or I THE PURPOSE OF ESTABLSHING A PERMIT FEE
am exempt from the provisions of tha Siate ot Californie Business
antl Professions Cotla, Divlsion 3, Chapter 9. VALUATION PERMIT FEE S �
SiBnature of a PLAN CHECK E /�
Permittae '�
�� .�f $ �p�82 r E
or � .L�C TAX S
AuthorizedAgant Date `—l3_'_� TOTALPAID S �
m
n
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OR m
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