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Home My WebLink About1590 ELM AVE - Building Permits lb .` s CITY OF COSTA MESA III t.6 BUILDING DIVISION , F d t.�77 FAIR DRIVE, COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us twill FOR INSPECTIONS CALL: (714)754.5626 PERMIT NUMBER: B09-00133 PERMIT TYPE B_ROOF2 STATUS: ISSUED APN: 13931216 DATE ISSUED: 07/21/2009 ISSUED BY: CAC JOB ADDRESS: 1590 ELM AV CM' • Suite/Unit: Vicinity: Squares: 1800 - ' . Valuation: _$4,900.00 SCOPE OF WORK: REMOVE EXIST,COMP. SHINGLES. INSTALL 30 LB FELT AND 30 YR COMP.SHINGLES OWNER: BRENDA STONE Address: 1590 ELM ST Unit: PHONE: 714-2355830 - City/State/Zip: COSTA MESA,.CA • APPLICANT: SERGIO AREBALO Address: 711 MONROE WAY Unit: : PHONE: 714-986-9920 - City/State/Zip: PLACENTIA,CA CONTRACTOR: CAL STATE ROOFING License No. 801616'':'-- ' -'• Address: 711 MONROE WAYUnit: - . . PHONE: 714.986.9920, City/State/Zip: PLACENTIA,CA 92870 ' - CELL: ' • - ARCHITECT: License No. - PHONE: ENGINEER: License No. . PHONE: • FEE SUMMARY Reroof Plan Check: $0.00 Reroof Permit Fee: $111.25 Reinspection Fee: $0.00 . - - Bldg Std Admin Fund . $1.00 tl:;t: TOTAL FEES $112.25 - - UniC . 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: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. 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. CODE O. INSPECTION TYPE DATE INTIIIALS CODE O INSPECTION TYPE DATE INTInALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final '1 l) 208 Final Plumbing t - 200 Final Re-Roof Z-• 3-09 k,6.U1tL/ 210 Final Electrical 201 Final Block/Retaining Wall / 212 Final Fire Prevention ..:.ii. . 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site .: .-°.":n? 204 Final Demolition 250 Final Building/Occupancy WORKERS'COMPENSATION DECLARATIO : Owner ID verified by driver's license. ❑Yes ❑ No; . I herebyaffirm under penaltyof perjury one of the followingdeclarations: �" P g ry Drivers License No. Expires: El I have and will maintain a certificate of consent to self-Insure for workers' Verification of Ownership by(type of document,i.e.-property tax bill or deed): compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers'compensation insurance,as required by s ion 3700 of the Labor Code,for the performance of the work for which this DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: p'•••it ' issued. My workers' compensation Insurance carrier and policy El I hereby certify that no excavation five(5)or more feet in depth into which a •r tuber a /� person is required to descend,will be made in connection with work authorized �1 —{�/ 1�/1 0 by this permit,and that no building structure,scaffdding,falsework,or demolition Carrier (a I Q \ V V I Q or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp Is section not be amdel n're/rm salued at/one hhunnnded dollars(3200)or less) 2,Ant Sec.341,Title 8.California Administrative Code). Policy Number: / `-� c� `v N El As owner-builder, I will not employ anyone to do work which would ❑ I certify that in the performance of the work for which this permit is require a permit from the Division of Industrial Safety,as noted above,unless issued,I shall not employ any person in any manner so as to become subject such person has a permit to do such work from the division. to the workers' compensation laws of California, and agree that if I should become subject,to the workers' compensation provisions of Section 3700 of Applicant's Signature Date th%%.or Code„I 'th comply .'th these provisions. /�� ....• ” /` it /Add �d2 /ry ` //le 9y Division of Industrial Safety Permit Number: / •ppllwnf znamre!/, /I lJ ! HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? ❑Yes ❑No ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS (Section 25505 of the California Health and Safety Code requires,with some PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. INTEREST, AND exceptions, that a Business Plan be filed with the Costa Mesa Fire ATTORNEY'S FEES. 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 LICENSED CONTRACTORS DECLARATION: 500 pounds,or a volume of 55 gallons,or 200 cubic feet of compressed gas I hereby affirm that I am licensed under provisions of Chapter 9(commencing at standard temperature and pressure). with Section 7000) of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file . e'in full force and effect. — , a registration form for acutely hazardous materials? ❑Yes ❑No _� Clas (Section 25533 of the California Health and Safety Code, with some `` �' exceptions, requires registration with the Costa Mesa Fire Department by �. /I r ��i/• SSSM._1 S• each business which at any one time has on hand a quantity of acutely Wairctor's-ignaiure 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 CONSTRUCTION LENDING AGENCY: temperature and pressure). El I hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to performance of the work for which this permit is issued.(Sec.3097,Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely Lender's Name: hazardous materials)? ElYes ❑ No (Section 25534 of the California Health and Safety Code provides that the Lender's Address: 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. Signature Dale 4. If an RMPP is presently required, has Section 25534 of the California OWNER-BUILDER DECLARATIONS: Health and Safety Code been fully complied with? ❑Yes ❑ No I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5. the work which is the subject of this application a permit for such construction Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from construct, alter, improve, demolish, or repair any structure, prior to its any other air pollution control district or agency? El Yes El No issuance,also requires the applicant for such permit to file a signed statement (Section 65850.2 of the Califomia Govemment Code requires that the requested that he or she is licensed pursuant to the provisions of the Contractors information be furnished on applications for non-residential building permits). 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 6. Will any part of the facility to be constructed under this permit be within the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? El Yes 0 No applicant for a permit subjects the applicant to a civil penalty of not more than (If"yes",the facility must meet the requirement of Sections 25534 and 42303 five hundred dollars($500).): of the California Health and Safety Code). El I, as owner of the property, or my employees with wages as their sole 7. If a permit from the South Coast Air Quality Management District or other compensation. WILL DO THE WORK, and the structure is not intended or air pollution control district or agency is required for the work which is the offered for sale(Sec.7044,Business and Professions Code:The Contractors subject of this application, have all of the disclosures prescribed by California License Law does not apply to an owner of property who builds or improves Health and Safety Code Section 42303 been made? El Yes El No thereon,and who does such work himself or herself or through his or her own 8. (If"yes",attach certificate of compliance from the appropriate air pollution employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of control officer). completion, the owner-builder will have the burden of proving that he or she CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the did not build or improve for purpose of sale.). information given above is correct. I agree to comply with all state laws and El I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH city ordinances regarding Hazardous Materials and Emissions. LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code: The contractors License Law does not apply to an owner of Signature Date property who builds or improves thereon,and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I a contractor(s)license pursuant to the Contractors License Laws.). certify under penalty of perjury that I have read this application and state that 0 I am exempt under sec. the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of Business and Professions Code for this reason: 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. Signajure of Legal Owner(s)tD Signature' Date /WWW � le Z //"'VVV3051x6(3/07) dlo Authonzed A plicant • a` 9 51N Ms 4 CITY OF COSTA MESA 4. °w •, BUILDING DIVISION F t ' PERMIT N R � DEVELOPMENT SERVICES DEPARTMENT 4,'#,�PI% • PERMIT EO 127 :arco (714)754-5273 • Fax(714)754-4856 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 1590 ELM AV Status: ISSUED Suite No Applied: 02/17/2000 Vicinity: REAR OF HOUSE Issued: 02/17/2000 Parcel Nunmber: 13931216 ISSUED BY: Applicant: HERNANDEZ, BRENDA Address: 1590 ELM ST Phone: (714)429-9250 COSTA MESA,CA Zip: 92626 Owner " HERNANDEZ, JEFFREY S_SR Address 1590 ELM ST - Phone: COSTA MESA,CA Zip: 92626 Contractor OWNER-BUILDER Address: Phone: • Zip: License: 0 SCOPE OF-PERMIT - REPLACE EXISTING 100 AMP SERVICE WITH NEW 100 AMP SERVICE IN SAME LOCATION. ' . FEE SUMMARY , , Quantity ____ Quantity ISSUE FEE , - $23.50 - - - Temp Dist System/Lighting $0.00 0 Temp service test • $0.00 Busway/100 ft,. $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res(1-2 units) $0.00 0 Misc Electrical Equipment - $0.00 0 New Res(3+units) $0.00 0 Transformers up to 1 kva/kw ' $0.00 0 Pool/Spa $0.00 0 up to 10 kva/kw $0.00 - 0 Lighting Fixts $0.00 0 up to 50 kva/kw $0.00 0 Recept Outlets $0.00 0 up to 100 kva/kw $0.00 0 Switches $0.00 0 over 100 kva/kw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System/Ckt $0.00 0 Service to 200a $30.50 1 Misc.Conduit $0.00 0 Service to 1000a $0.00 0 Misc.Conductor $0.00 0 Service over 1000a $0.00 0 Circus(gen or ride) $0.00 0 Motors to 1 hp $0.00 0 Circus(mech ride or lights) $0.00 0 Motors to 10hp - $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 ' 0 Communication drops $0.00 0 ' Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 • NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord. No.92-28,§1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTION$CALL: (714)754-5626 1 . T V DECLARATIONS . ( 1 n • WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I 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. ❑ I 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'compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars($100)or less.) ❑ 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 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 provisions. Applicant Signature: 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 3706 OF THE LABOR CODE.INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS 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 Code,and my license is in full force and effect.Lic.# Class# Contractor's Signature: Date: 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.(Sec.3097,Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I 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).): Ir 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 Code: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 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-builder 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.). ❑ I a e�f'pt under s-c. _ Business and Professions Code for this reason: Signature: A1AL—LL ./ C' 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 a permit to do such work from the division. Signature: Date: 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 to release or threatened release of a hazardous material? 0 Yes ❑No (Section 25505 of the California Health and Safety Code 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? 0 Yes 0 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 an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes U No (Section 65850.2 of the California Government Code requires that the requested information be fumished 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). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? 0 Yes 0 No B (If'yes",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 state 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. I. t e Of Legal Owner(s) 02— / 7—Dat D • And/Or Authorized Applicant ' Date • CODE r WSPECTION TYPE DATE 1NTRIAL$ CODES INSPECTION TYPE PATE INT1TIAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical !l— //�� )—rr7 201 Final Block/Retaining 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 2446.46 • DECLARATION OSUTHORITY Bldg. Permit tt• FOR AGENTS OF PROPERTY OWNER This Permit ft TO APPLY FOR PERMITS PC/0 E/, Ate . • StreetdtrAddress AP Number 1. I (we), TO��/ Qy ! / TY)9nZ , declare that I am the Owner of Title of the above referenced real property, and that I (we) hereby authorize: re,n.cLa (2/9) y29 -5 2 S' Name Telephone No. )61'6) g/i)'] Street Address Cos-j City State Zip to obtain permits in my behalf, as owner/builder, for ELECT/flC ME<t=12Per2tAl I at the above referenced property. 2. Should any person become an employee engaged in the improvement of the property, I (we) shall im- mediately provide Worker's Compensation Insurance coverage and cause a certificate of that coverage to be filed with the Building Division of the City of Costa Mesa, as required by State of California laws. 3. As owner/builder in fact, I understand and accept that my responsibilities do not transfer to any other per- son, company or corporation. 4. I agree to indemnify and hold the City of Costa Mesa and its employees or officers harmless from any claim resulting in damage or personal injury to myself or any other parties as a result of work authorized by the permits from the City of Costa Mesa. 5. I declare under the penalty of perjury that the foregoing is true and correct. ✓h Executed this /6 f4 day of F� b d8��, at 11? /'/44—", California. Era r,/ rantpinQndez Sr; 21i 4700 ed Name ,� Dat I OK / Pi// / �" �gnature NOTE: This authorization does not grant authorization to perform the work as owner, it solely provides for limited power of attorney to secure this permit in any behalf. NOy6R9TI$ R/OU141 0779.46(Rev.2/9t( . . 107435 I COSTA MESA BUILDING-SAFETY DEPARTMENT FEE RECEIVED P.O.BOX 317 COSTA MESA. CALIFORNIA 4 "- O FOR APPLICANT TO FILL IN COMPLETELY AppmANBENDEM PERMIT TYPE OR PRINT cnv c Paco MtSA ADD°ESNs 1590 Elm Street l� COSTA MESA. CALIFORNIA FOR OFF/CE USE ONLY RECEIPT NO. PERMIT NO. OWNER Knightwell Land Company re`% -,_ AMAIL DDRESS 419 E. 17th Street RE°E�E %ATE=EQF�NE DAv ED95i CITY Costa Mesa, Calif. TELL' 81159NO. ADDRESS /—Y— (/� J V' '11 ARCHITECT Carlson & LIC. COSTA MESA. CALIFORNIA OR ENGINEERR1jdI1]ehrnnk NO. ADDRESS Garden Grove FIRE � o e� /�' ZONE TYPE GROUP V' !U//y Dike Colegrove, Inc. STATE APPROVED CONTRACTOR LIC.NO. BY DATE ADDRESS 419 E. 17th St., Csta Mesa u ZONING L LEGAL LOT 88 3487 ZONI/FV / NO.OF USE OF NEW I/� DESCRIPTION NO. BLOCK TRACT 1� /f PLANS 1 _I.BUILOING 1/✓ APPROVED1111 / �/�(� DATE / 1r3 �'/ A.P.NO.. BY w f //�� SIZE 751 x 1001 . INC)*OF BLDGS.NOne YARDS FJ✓E$'�- OF LOT NOW ON LOT REQUIRED ALLOWED USE OF (CENTER LINE ST.) EXISTING BLDG. None FRONT FT. IN. SETBACK LINE FROM �1 CENTER OF STREET 5 1 REAR YARD 271 R.SIDE ) FT. IN. SIDE YARD LEFT 101 L.SIDE / 0 FT. IN. DESCRIPTION OF WORK REAR g ///��1 ' / FT. IN. NEW X I ALTERATION V ADDITION / REPAIR I II MOVING _ II DEMOLISH I ' BULS ZIE DING 1601 ROOMS 6 STORIES 1 EXTERIOR WALL , ROOF e COVERING succo COVERING Shaker USE OF BUILDING AND WORK TO BE PERFORMED Single family residence with f ,y' •/a attached garage 6 Plan 760 A I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO CON. PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. PLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING BUILDING CONSTRUCT] N. VALUATION SIGNATURE OF _ PERMIT FEE S 36.00 PERMITTEE PLAN CHECK $ 18.00 Dike & C legrove, Inc. 1.36J-L-4--- 54.E AUTHORIZED AGENTTOTAL FEE $