HomeMy WebLinkAbout119 DEL MAR AVE - Building Permits fHER119ESALDEL IN MAR AV UNIT: CITY OF COSTA MESA — BUILDING PERMIT PERM NU: H 059133
: 119 DEL MAR AV PERMIT NO: B 059133 PLAN CHECK NO: N &UVt ; N 5urt'; N
COSTA MESA
CA 92626 CONSTRUCTION TYPE: 5—N PERMIT TYPE: SIR PURPOSE: ALT
• ( 714 ) 248-2688
1J ARCH/ENGINEER: REG.NO.: JOB DESCRIPTION ; REROOF W/ASPHALT COMPOSITION SHINGLES SQ FT; 2, 400
ADDRESS: UNIT:
CLAIM VALUE: 2, 400 . 00 CALC—VALUE: 2, 400 . 00 GROUP OCC; R-1 /M-1
PERMITTEE: GIANT ROOFING ( 714 ) 595-2546
ADDRESS: 1740 DESIREAV COMMENTS: SMOKE DETECTORS REQUIRED PER 1991UBC
ROWLAND HEIGHTS CA 91748 ******** ******************* *****************************iE********************
LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section ZONING REQUIREMENTS
7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect. SETH ACKS
CITY LIC.: 056996 STATE LIC.:525287 cross: C-39
MAIN BUILDING ACCESSORY BUILDING
Date: Signature: FRNT; FT IN REAR: FT IN FRNT; FT IN REAR; FT IN
WORKERS'COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self-insure or a certificate of Workers' LEFT; FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN
Compensation Insurance,or a certified copy thereof(Section 3800.Lab,C).
POLICY NO.: EXP.DATE: PARKING REQ- PROV; PARCEL; 43917117 ZNE; REF NO:
' ,1CO�OMPANY: PLANNING N TES>
-_i Certified copy is hereby furnished- ❑ Certified copy is filed with the city Building Division. >
**************************************************************ii**********Fe*****
Date: Applicant DEVELOPMENT SERVICES R E Q U I R E M E Ni,T S
EXEMPTION FROM WORKERS'COMPENSATION DECLARATION: (This section need not be completed if the permit is fpr one hundred($100)or less). r
I 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 f'/
subject to the Workers'Compensation Laws of California. . ZONING APPROVED BY _ _ DATE:
�— Dale:Ci"/7'q'L Signature: �1�lTh:�_ BUILDING APPROVED BY , DATE: .r
NOTICE:If,after making this declaration,you should become subject to the Workers'Compensation provisions of the Labor
Code.you must forthwith comply with such provisions or this permit shall be deemed revoked. �Y7 G
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for APPLICATION ISSUED B Y; /�, •L • DATE; >✓� l•T 9"2_
which this permit is issued(Section 3097,Civ.C). **'***'*******f(-'****'!(-*'R'***it###tititill!*xTc it* ,c**** *** ***rt9'********** FFF "k * *****
LENDER: ******************************* ***** .** .***********************************
ADDRESS: LEGALIZATION;N F E E SUMMARY STRUCTURAL SEGMENT:Y
OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors'Slate 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 PERMIT 54 . 00 ) 50
repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he/she is licensed .. SMIP/NON—RES
pursuant to the provisions of the Contractors'State License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business PLAN L
and Professions Code)or that he/she is exempt therefrom and the basis for the alleged exemption Any violation of Section 7031.5 by ISSUE FEE rj,.
any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500). •
BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL ' PAID DUE
I, as owner of the property or my employees with wages as their sole compensation, wit do the work, and the TOTALS 54 . 50 0 • 00 0 , 00 54 , 50 v 54 . 50 , 00
❑ 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 REVENUE DIVISION TOTALS--> COLLECTED : 54 , 50 OVER/SHORT; 00
improvement is sold within one year of completion,the owner will have the burden of proving he/she did not build or improve BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK
•, for the purpose of sale).
I.as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business 54 . 00 ,�0
❑ and Professions Cotle'. The projects with
License Law does not apply loan owner of property who builds or improves thereon *******************************************************. .***********************
and who contracts for such prnjects with a e License
)license pursuant to the Contractors'State License Law). I am aware
that proof of their Worker's Compensation insurance should be provided to me. INDIVIDUAL F E E B R E A K D,jO W N
❑ I am exempt under Section: B.8 P.C. ..d..-
for
ffor this reason: TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST
•C
Date: I l/7..---- t2Owner: a._ SFR 2400 ALTER BY VALUE RESIDENTIAL NOZONE . 1 ,.00 2, 400 , 00
I do hereby certify that I am aware of and understand the requirements of California Mealth and Safety Code Sections 2550'' 5533,and END OF FEES
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 . Li
permit for construction or modification from the Air Quality Management District.Residential construction applications are exempt from .. 41 '
these provisions.
A % f
Date: Applicant: t T
I hereby certify that I have read this application and state that the above information is correct.I agree to comply with all city and county 14 9
ordinances and state laws relating to building construction and hereby authorize representatives of this city to enter upon the above-mentioned - 1
propertyylxr inspectionct$ purposes, J -1\
]� (t I I�
Date:Ti r'/'—/ L \
Signature: � l -_
n1 Gsa]01chi' ;,;., _ -
Driver sLicense orSocial Securit a:
1641-46 White—Building:Green—Code Enforcement:Canary—Applicant;Pink—Revenue:Goldenrod—Assessor
1 I
fR• OCT1O1CAND PLANNING - PO. SPA
PVALS
Permit # Date Inspector APPROVALS Permit# Date Inspector-
orary-Electrical Service or Pole 52. Pool & Equipment Location
ipe•Undrgrnd. 53. Steel Reinforcement
ti
3. Electrical Conduit Utility-Undrgrnd. 54. Forms - . n
4. Electrical Conduit-Undrgrnd. 55.. Electrical Bonding
5. Steel Reinforcement 56. Rough Plumbing & Pressure Test
6. Electrical OF ER Grnd. • 57. APPROVAL TO COVER-GUNITE
7. Footings 58. Electrical Conduit-Undrgrnd.
8. Foundation -4' 59. Gas Pipe, 0 Undrgrnd., Test
9. Water Pipe-Undrgrnd. - - 60. Backwash Lines, P-Trap, 0 Undrgrnd.
v.
10. Structural Floor System 61. APPROVAL TO DECK •_
11. Property Sewer Line & House Connection 62, Backwash & Receptor-Final 1
12. Sewer Cap - 63. Heater & Vent-Final
i 1
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
r
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING '
•
18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace - - APPROVALS Permit # -
21. Ducts, in Structure 70. Underground Hydro
22. Ducts, Ventilating - - - 71. Product Piping 0 Gas ❑Oil
23. Gas Pipe-Rough & Test 72. Underground Flush
24. Roof Framing 73. Undergrnd.Storage Tank 0 Gas 0 Oil
25. Root Sheathing - - 74: Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat - 75. Dry Chemical
27. Frame and Flashing 76. Dry Standpipe
28. Lathing& Siding r 77. FIXED SYSTEM FINAL
29. Insulation I !: 78. FIRE PREV. FINAL
30. Drywall-Nailing - _� HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat I I j` 79. FINAL INSPECTION
32. Electrical Power Meter-Finali .r ;- 80. FOOD CERTIFICATE ISSUED
•
33. Final Electric 'I __E Notes:
34. Final Heating& Air Conditioning j , i 21
35. Final Gas Pipe-Test f 7 ,� ' •
36. Hood or Canopy i ! j.
37. Final Factory Fireplace I
1
38. Final Plumbing
39. Water Service-Final I 1
40. Gas Service-Final - I l
41. Solar Domestic-Final - I
42. Backflow Preventer
/O-2- e 1 e
43. Backflow Irrigation
P-1-6
- „ c-/-e._
•
, 44. Landscape Irrigation System .
bawd
45. Sound Attenuation
46. Handicap Regulations
47. FINAL STRUCTURE & BUILDING it/3 72- P20-
48..
-48. FINAL PLANNING
49. Electric Release to Edison
50. Gas Release to Southern California Gas Co
51. CERTIFICATE OF OCCUPANCY
No. Date
CITY OF -A MESA
PAR, .IES
Fee Payment Receipt
N° 551
Project Address //9 / OCL/'. itt.p
A.P. Number y351 — /2/ - / 7 Park Area .3
Building Permit Number 6e{7 C o 7
--Owner's Name U C+.P t\\(--t .J L lPPA t k1
Mailing Address 301 E . BAJ FlR-pN\T1 BAL.l30P< I SLAM)
FEE: Single Family * Number of Units
2-Bedrooms or Less @ $ 861.76 =
3-Bedrooms @ 1,205.67 =
•
4-Bedrooms @ 1,545.62 =
5-Bedrooms+ @ 1,810.50 =
Multiple Family **
Bachelor or Studio @ 474.37 =
1-Bedroom @ 573.18 =
2-Bedroom @ 881.51 = 77e 3. 02
3-Bedrooms-i- @ 1,392.72 =
Total Fee *** /A 5-0.7-.
PlanningDepartment App l Date nce 72. >� By--i-�'
.�– Applicant's Signature pny/
* City Ordinance 72-44 ** Cit rdinance 72-V * y Resolution 78-116
CMF 0174-32 Rev. 1/79 White—Planning;Canary—Planning;Pink—Finance;Goldenrod—Applicant linl
`•_ 8699 5[12179 145. 0 Tl
•,��..' COSTA MESA BUILDING-SAFETY DEPARTMENT APPLICATION F TR p5([,:aL' vet"•-• IA7LKTL1�
P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626 !L. Ll �❑F7 (A
1 REC BY PERMIT a /7 /r ^ �/
For Applicant to Fill in Completely —Use Ink Only Yt` !Y^/(j1�
'ADDRESS
+ t^ � –L (A fa-4 /� A.P. NO. �39_ /7/��7
ADDRESS L `-t bec..._ C.
BUILDING
OWNER OR — �n ` '^) ADDRESS
,U
TENANT (is.el.‘Ne `Li tOl.s�.
' UNIT OR
MAILING �^ a SPACE NO.
ADDRESS
)0\ A9 rienin T 2
CITYT�,L2g� 15 LA t�� NO.6.400163 TN ADD ALTER REPAIR MOVING DEMOLISH
CONSTRUCTION Y
LENDER
BRANCH
OWNER
ADDRESS USE ea E$
ARCHITECT TEL.
OR ENGINEER NO. D
ADDRESS ZONE f� TYPE GROUP Si
APPROVED
CONTRACTOR °WtN\e A BY DATE r/,7/L 7
ADDRESS
TEL.
CITY NO.
Fr. STATECITY APPROVED SETBACKS
i–iLIC.NO. LIC.NO.
W SIZE NO.OF BLOGS. A (FROM WI_STREET)
C. OF LOT `O a c L O et I NOW ON LOT
.....
FRONT FT.
y - USE OF �, ^)Gce r�oa n S
EXISTING BLDG. >tIN L� R SIDE FL
rA
FSeparate permits are required for L.SIDE FT.
C electric,plumbing and heating work: REAR FT.
FUSE OF BUILDING AND WORK TO BE PERFORMED PLANNING ACTION
,,,,f�yll./ DATE
K _ CXLSTIt4 &- EusthLl�`� APPROVED
Q (�C
APPROVED
>-. c'el —alt DATE
..I
1414 —
Ow I hereby acknowledge that I have read this application and state n
that the above information is correct and agree to comply with
04 all laws regulating building construction, and I shall not employ
Z any person in violation of the workman's compensation laws of •
L the State of California. - -r
m
I hereby certify that I am properly licensed as a contractor under SO. FT. a
the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR m
Chapter 9, and that such licenses are in full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY:
to
am exempt from the provisions of the State of California Business VALUATION PERMIT FEE $ Y
and Professions C e, Division 3,Chapter 9. ,�s7 • OO at .
m
Signature of ^ PLAN CHECK $ o
Permittee / $ TAX $ f
Authorized Agent Date lS 'L? ' 9 /346 / U
- TOTAL PAID $ d/ V
T.
..-- 0+760$ 4'{i'?2'"'3706%79 74.95 IL
COSTA MESA BUILDING-SAFETY DEPARTNt2Nlr--lam^ r
P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626 i
APPLICATION FOR STRUCTURAL PERMIT
For Applicant to Fill in Completely—Use Ink Only
R ECEI BV DATE RECEIVED ;DATISSU D i
BUILDING
llq beL MAa <7 79
ADDRESS �7
OWNER EUGeac Lt\?PoiK- N ,TOMLto A.P.NO.l.739-77/-/ / sr
be
MAIL - /r BUILDING
ADDRESS 2a rt Pot t. tse t (_ A ADDRESS / �4,c
CITY CoLoNA be-k._ MAC/� TENO.L. ps_This.Th-tqs TRACT 3 77 1 LOT% BLOCK
CONSTRUCTION NEW ADD ALTAR REPAIR MOVING DEMOI ISH
LENDER X/
BRANCH
OWNER
' ADDRESS M /1y] V`p ,, r�jjS
ARCHITECT TEL. USE Q/1\OU' Ex1e\ ).Uk!5 .
OR ENGINEER NO . , .. ,_ ... ....... . ..._
FIRE
ADDRESS ZONE TYPE GROUP
r /�j
CONTRACTOR 0t.J h1C\2'$ APBY
DATE J i7/ /4
ADDRESS / /
TEL. ZON NO.OF USE OF NEW,1 •
CITY NO. PLANS 2 BUILDING / l/t
STATE * CITY YARDS APPROVED YARDS A/P`P�ROi D
g LIC.NO. �" ""e LIC. NO. MAIN BUILDING ACC ESSO LDING
c � 1
G SIZE OF LOT I O'1 K (�a NO.OF BLOCS. (FROM C/L STREET) CES
NOW ON LOT TONT -T.
-
/V T. ,
USE OF Ca EXISTING BLDG. N(Jthe. S/��2 -E2/Y1 . ` • R.SITIF ' I A. ,/Ca I / ' FT.
V
HSeparate permits are required for L.SIDE ✓ Ir �C iii2, 1 FT.
C electric,plumbing and heating work. REAR T. FT.
USE OF BUILDING AND WORK TO BE PERFORMED
VS
'
TZ DISTANCE BET. BET.MAIN&
'Re m ors& G K t 5Tt.1 to- 6t&I L.I)t par MAIN BLDGS.. ACCESS.BLD//GS. 7 cry-
'Z'
�
' Y: , , . , a _A p\Q h '' _ r _ —C U.P#Y/APPROViefetee._ /7/�O L APPROVED Y --co '/-7/
- �.Y t DATFA
a
w
O. I hereby acknowledge that I have read this application and state - R� onn.-S^.' r t
rRaimaffifieriez.. in
N.
X that the above information is correct and agree to comply with m
Q. all laws regulating building construction, and I shall not employ u
Z any person in violation of the workman's compensation laws of •,/}•�/ / m�
,��. the State of California. �/ a•SQ. FT. V 0`
�
3 I hereby certify that I am properly licensed as a contractor under
the State of California Business and Professions Code, Division 3, HE AMOUNT SH UNDER VALUATION IS FOR w
Chapter 9, and that such licenses are in full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY:
am exempt from the provisions of the State of California Business aVALVATION •ERMIT FEE
end Professions Code,Division 3, Chapter 9. n
/ �/ i le- PLAN CHECK $ 7a 5 b
Signature of
Permittee ,� �t-Q $ /I TAX $ 6 /�� 2LL
Authorized Agen /] ��
S TOTAL PAID $ / /
/+ ¢ 447.1 3/06/79 g ,�i�q
��t'r7C7� ( �<< p'471 3/06/79 `I66euyLKT�
COSTA MESA BUILDING-SAFETY DEPARTMENT ' ai';4TI: 00004476 07,i
P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626 �'1v
APPLICATION FOR STRUCTURAL PERMIT
For Applicant to Fill in Completely —Use Ink Only
(] t� r� REC �/{/� BY D. REC IVSD DAT ISS/UJED
ADDRESSG l ( l I-t��l` bel_ Mph ��,�; —�7/7�79 5 /7/ 7�
OWNERI=t 6Cte LIMA< '- b4. I i�'Mi-.tt.) /1 ' —/ ///7
PE MIT}VO.
A.P. NO. 7
MAIL _ BUILDING /^y/n
ADDRESS ��1 Pot. 1lSeTl A ADDRESS 1/9 /�/ !/!a r 4
TE
CITYC O A"bel_ Iv IAC NOIfe7 s±,agc ` TRACT 37(6Ir LOT L{7 BLOCK
CONSTRUCTION NEW ADD ALTER REPAIR MOVING DEMOLISH '
LENDER
BRANCH
/OWNER
a ® ADDRESS /^� UE
ARCHITECT TEL. USE LAYLE ilk/ $ '
OR ENGINEER N .,..... . . :.. - .._ ......._,
FIRE
ADDRESS ZONE TYPE GROU�1
APPROVED rill??CONTRACTOR Cu . d1 AA e, 'S BY DATE 7
ADDRESS
TEL. ZO ^J Na OF USE OF NEYG
CITY NO. 2T PLANS BUILDING /1>/Aj�/n
i-i STATE CITY YARDS APPROVED YARDS APPROVED
LIC.NO. '7) LIC. NO. MAIN BUILDING - ACCESSORY BUILDING
A
(FROM C/L STREFT) / /�/1 //A /��-U/7
4 OF LOT LO't )L IQ�14 SIZE I NOW ON LOOT 1 FRONT1.5e)F€. (L tom' ,O7ar
hUSE OF Q �J
.. EXISTING BLDG. 4OJIA` R.SIDg-2q ,T. /i 'r//v2S F�V�j �/R/e/
tn ESI Separate permits are required for L.SIDE S FT.0 FT.
electric,plumbing and heating work. / h
- - REAR // FT.L J FT.
USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET.MAIN&
MAIN BLDGS. ACCESS. BLDGS.
k
DATE
3;2
eIhbcL txl�;tl.b_ 4:1(1.1-rt,—..as C.U.P.#;e 749-0,x,. <-77aLt —JR crew \ LacK
*C ,aGe ^ �
DATE / 77
/7'
n! .—. Cr..—_... E
—R -rJ:..r.....
W - r .a. .......A
CI hereby acknowledge that I have read this application and state C
ce that the above information is correct and agree to comply with
a
all laws regulating building construction, and I shall not employ
Z any person in violation of the workman's compensation laws of #24
JJ
the State of California. _��� �
/ O t ^r] aatey\Z
I hereby certify that I am properly licensed as a contractor under -
the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN DER VALUATION IS FOR al•`
Chapter 9, and that such licenses are in full force and effect,or I THE PURPOSE OOF/ESTABL RING A PERMIT FEE ONLY: 4
am exempt from the provisions of the State of California Business
VALUATION n PERMIT FEE
•
and Professions Code,Division 3,Chapter 9. C `�r/ (/%/f $ 9 /�
. PLAN CHECK $ _/' ((boo
signature of /� �I •
[
Permittee �.C.C},QiHQ g (�rAi $� TAX $
t�/// �/// / / ` �7 t
Authorized Agen TOTAL PAID $ R
COSTA MESA BUILDING-SAFETY DEPARTMENT APPLICATION F®MFRI;i9T- PERMIT! .
9.1•DD T .
P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626 /) —�..��`� C?1PjP1,1' DOCK!
For Applicant to Fill in Completely�t / — Use Ink'Only RECEygE ■ ,._"- 0074 4.,...0.77-
.,r .._.. A
BUILDING 9 )e-l_ /srt-J�F� Oa e4#45 A.P. NNOO... �{,3, tl.... /71 - /7
ADDRESS ' l BUILDINGn �/,/��.�
OWNER OR EAA- ti1Q . I `�ON)lC ADDRESS 1/ i!ag /20e•
TENANT C. J l_ l`-' A
MAI LING //// UNIT OR
ADDRESS 30t 3Ry FL 4�1 11l,P ct SPACE NO.
}� I
TEL. LOT
r- TR.f�7g LOT 2/' BLK.
CITV at M. tS NOL cot-1-0 MO J G(O
CONSTRUCTION NEW ADD ALTER (REPAIR MOVING DEMOLISH
LENDER X
BRANCH /
OWNER t di.. / 44ZAta
ADDRESS 44-ARCHITECT TEL. USE
OR ENGINEER NO.
ADDRESS pp ZONE IZ�/j/ TYPE 1 J
GROUP
CONTRACTOR 0IA.J t.�eA BYPROVED V r+ 7/
BV I DATE /J r/�/r 7!p
ADDRESS
TEL.
CITY NO.
E• STATE CITY APPROVED SETBACKS -
gLIC. NO. LIC.NO.
f.T4 SIZE L OF LOT I O). X t 0 2 NO.OF BLOTS. (FROM ETT) 1 ( /J
NOW ON LOT FRONT J�/s0� FT. �[�L/.
Q USE OF L-\O OA_ e R.SIDE 4T'FT._ TO e�ef• •
� EXISTING BLDG. Air
rn r
FSeparate permits are required for L.SIDE S FT. Dr
electric,plumbing and heating work: //r A
IO REAR �'I FT. O
ti USE OF BUILDING AND WORK TO BE PERFORMED1PLANNING ACTION
DATE
< tLA.\Lb [ IPI.\J t(A 'Js-<=X APPROVED _
NEA- G A pl.A-CA e _APPROVED DATE
Y�
IY
W
0 I hereby acknowledge that I have read this application and state m
cd that the above information is correct and agree to comply with
G. all laws regulating building construction, and I shall not employ i
Z any person in violation of the workman's compensation laws of 2
.'.L" the State of California.
N• FT.
I hereby certify that I am properly licensed as a contractor under SQ. N
the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR m
Chapter 9, and that such licenses are in full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: —
to
am exempt from the provisions of the State of California Business a
VALUATION PERMIT FEE $ `v ,D� N
and Professions de,Division 3,Chapter 9. m
PLAN CHECK $ rn
Signature of . ^ 0
Permittee (A 6J.PiGLQ A $ .-S ' TAX $ L
or ) U
(//Authorized Age Date TOTAL PAID $ /9/6171
U