HomeMy WebLinkAbout3080 COUNTRY CLUB DR - 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: 3080 COUNTRY CLUB DR
Suite:
Vicinity: RESIDENCE & ATTACHED GARAGE
Parcel Number:
13916304 Zoning:
R1 R1
Applicant:
OJEDA, GUSTAVO
Zip: 92626
Address:
7472 SLATER AV
Permit:
Address:
UNIT B Phone:
714-5964443
SMIP Res:
HUNTINGTON BEACH, CA Zip:
92647
Owner:
SCHWEININGER, FERDINAND T
$0.00
Address
3080 COUNTRY CLUB DR
License: 771916
Arch :
Address:
Eng:
Address:
ISSUED BY:
.Status: ISSUED
Applied: 11127/2000
Issued: 11/27/2000
Phone: Phone:
Zip: License: License:
SCOPE OF PERMIT
REROOF: TIO EXISTING SHINGLE ROOF, 1/2" OSB, 1 LAYER OF 30# ASTM FELT, INSTALL 40 -YEAR "CELOTEX
RESIDENTIAL" COMP SHINGLES.
37 SQUARES
Phone:
COSTA MESA, CA
Zip: 92626
Contractor:
ACTION ROOFING SERVICES
Permit:
Address:
7472 SLATER AV
Claim Valuation: $10,500.00
SMIP Res:
UNIT B
Phone: 714-596-4443
HUNTINGTON BEACH, CA
$0.00
Zip:
92647
License: 771916
Arch :
Address:
Eng:
Address:
ISSUED BY:
.Status: ISSUED
Applied: 11127/2000
Issued: 11/27/2000
Phone: Phone:
Zip: License: License:
SCOPE OF PERMIT
REROOF: TIO EXISTING SHINGLE ROOF, 1/2" OSB, 1 LAYER OF 30# ASTM FELT, INSTALL 40 -YEAR "CELOTEX
RESIDENTIAL" COMP SHINGLES.
37 SQUARES
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) 754-5626
2446-06 (6/00)
FEE SUMMARY
Plan Check:
$0.00
Calc Valuation: $10,500.00
Permit:
$195.25
Claim Valuation: $10,500.00
SMIP Res:
$1.05
SMIP Com:
$0.00
Other:
$0.00
Inspection:
$0.00
Total:
$196.30
PLANNING & ZONING
SETBACKS
MAIN STRUCTURE Front 0-0
Rear 0-0 Left 0-0
Right 0-0
ACCESSORY
Front 0-0
Rear 0-0 Left 0-0
Right 0-0
PARKING
Existing: 0
Required: 0 Proposed: 0
NOTES:
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) 754-5626
2446-06 (6/00)
WORKERS' COMPENSATION DECLARATION:
I h eby 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 far which this pernd is Issued.
My workers' compensation Insurance carder and policy number are:
Carrier: Policy Number:
(This section need not be completed i/ the permit is valued at one hundred dollars ($100) or ess.)
❑ 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 th ouldecome subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with the Cr r�ov Ions.
Applicant Signature: \ ` \fo'F,L. rho r N1 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 #
Contractors Signature: 6 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 Cade).
Lenders 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).):
❑ 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.).
❑ 1 am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires:
Verification of Ownership by (type of document, I.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 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 W i11 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
me arlal? ❑ 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? ❑ Yes ❑ No
(Section 25533 of the California Health and Safety Cade, 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.
......................................................................................................................................................................................................... ...................El.....................................................................
4 If en RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully tom... .. with? [*:**]***Y* as ❑ No
..................................................................................................................... ildi........................................................................................................................................................................................................................................... difi................
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication apermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? � Yes ❑ No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
.................................................................................................................... .....................................-........... ..................................... .... ...... ..................................................... ...................................... ..................... ...... ...................... I ........... I.............
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
(It "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
............... ...... ............................................................................................................................................................................................................................................................................
7 II a permit from the South Coast Air Quality Management District or other air pollution control district n agency is required 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
............................. ..........................ific................................................................................................11ut................trol................................................................................................. ............................................. .....................................................
e (II "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.
S' nalure gal Owner's) Date
And/Or Authorized Applicant Date
CODE INSPECTION TYPE DATE INTITIALS CODE# INSPECTIONTYPE 2&U Its
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Ra -Roof /Z —8 —Uo 210 Final Electrical
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
CITY OF COSTA MESA
BUILDING DIVISION
ROOF COVERING CERTIFICATION
Permit No. z!�p o49�R1
Property Address 30 CA' Q" qty cic/b 1>r- Cm -4a VALA C -
Owner sc`1Wp�t14e1Gw-
Contractor i*Yj,.o A 120aIr-11 ' e1MA'CA-S
State Contractor License Number -7 Z9 lG Classification
I hereby certify that I have installed, or caused to be installed, a minimum Class C roof covering at the
above address in conformance with Chapter 15, and Appendix 15 of the latest adopted edition of the Uniform
Building Code, and the installation instructions of the manufacturer.
❑ I further certify that I am the owner of the property. (Owner -Builder permittee only).
t2" I further certify that I am:
Owner of sole proprietorship company
❑ Full partner of the company
❑ Limited partner of the company
❑ Officer of the corporation
I certify that as an authorized officer or agent of the company or corporation, I am empowered to make this
certification, which shall be binding on all successors or assigns of the company or corporation.
I shall deliver a copy of this Certification to the above listed owner, after submittal of form to the Building
Division for acceptance.
Received by Building Division
By:
Z
I ilal Date
0920-46 MW BOO White -Building Di¢;Canary - Contractor; Pink- Owner
Company or Corporate Name
Address
Signature Date
Printed or Typed Name
' \ i• _;r; l:."l:. •%. fin,;' t i//r
April 13921962
_ -J, 1. fi �r -• •n F.+ _gip I ,
11 If
r j r Rr Roy 'A .StechrboaQ: : ' t ,
30ao Cofiht* :Club Drive -
Costa-Zasa9.Colifornia:
Ros Rain Datac69 Tract 3363; :Lot 116 Codd;requirerae s o£ Chapter,289
Section 2805(a),states in part9
"second ie n66 of tho'second para
:.` raph, u2oundation Faallscsugporiii good, a end 'at ianat `s3as '
icacP�os`abovo: the finished'grade .ad9acent the`uall a6 all;pointe.a y;
•
be Ems. StoclQne3ser: , y v s
.•; - t
arrived. at your aidanc0 +ot -20, 00 J_: -f on t aach 2, ;]962, . 'for the l
f purposo, 0-inspegting,repo ed damn. -o to hour. F s.iSteciaoseer.called your
4 - from your, ver$ 'and you arr4 , .d ;shortly. efts 10aQ0Ata. ,`;Prior ,to' your, arrival I
r ; visa introdud o a p iibdr o, 1aaa caorkir�; Gat` his trade on the interior palls ,
O -sof your i?ra� , 11 crack0M1' ui"-repainting. .I checked weect om of ,i a17 at -the
firoplaca`;and erai]`ro on iIiie`interior adetion had'been completed., I
{ , ` also;rtited othe cracks 9n •ttio• repair stageq. noted door head'`'amb Beit. oYY of ,level
;t s ..; . position irlth at ached wood ,mold to'h trac2c: oY door�:.at'.top;section; ar the I
lcitchon-_cabinsta,out' o£`°6g4oi�o,-aith va11 u rolatien to`•theii griginal.sett�:
Upon aoing outsidd#-qr visual inspection of your$residentiol structure
- revealed-tho fo]llowirefl '
tr ' 1) ho'iinn:1.bh d=eorthIgrade•in reiation to yoiu fini0hed coi�ut;floor
Has 'not si i' i aches bolow.,'hAi sfi d floor. :This occurs nt-;the ' south
east i�a17.9=.and t,*th,, 1l
i oai H gall. at the =fireplace' aeetion-;I noted -`a ir&i a crack .
-'UndeP the-S!'iSldott:'froffl�Che €ir@p see toxtcti4=garage cxill'and'oals6,;i.•.
frons the €3replace to the hind . at tho top section. =
r th Fk
3) ' Qn; the' "section- oastr of-the'=firepIaco onr the' north. Fiiali.alon;� the `I
;bottoms aeotxori Hoar the 'nolo platco9 thcr gloater..iif b uneven ark; in
gond place isent to'tho boatom of the.,sola y�lote only.
le) IL'r appears ISrtml a :slight, diacolorntion "to: carpets at t3a� fieplace
section ti�at moistures has sc epefl in under ;the solo'plate
IIre ,Roy Ac Imesser, t • ' t m t - z c c '
r ".April: 13D ;17\+2
Pate
t
5) 4 3s ayq opinion thatif'and',u nnothe pr9per gradin;'-vork Is
c6mpletod: thehast d `from excessive watbi° .co -at the
foundations<vill.be oliminated.'-Tho win9tallation o£•,roof
f .
. ;gutters; crould. also Ue;of, gTiaat 'holp 9.ri carryix�a, the roof runoff.
cutter to' tiro or: threo centrA locations. th6roby-lessen9.n;'the
F Hazard,6P`vater;collectinn;a�aiast,'tto foundations of.a11•walls .at#
. in 'question: i
f the `deparimem can' bo of an further aaaistance to -you, l please x
advise. {'
i. 1 •\1 M �:r re
•N', ,t S L f..•
' .. a S a - ' \,•. r VCrjI tPlLly j/dUP8D1
-C 11
.� ` ' u;1 . 3�ehael•� Hfr�haII . '"s
•' � 5 y
cc e Donald an, • uty,Att rmy ,
♦
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17
y F:y
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�
r Y •r l S y J- # .#�" r i y - 1 •. St. 1 r l a1 .� , - s - ? ..
1.
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January`23, 1962 t ,
Mr. Walter Geynor• >
Jamaica:Construction Company
-3120 Bermuda'Drive. ,
Cost a,Mesa,;California
9fJ&TFxT Ebundation wale supporting wood ,80tion 2805 (a) Uniform Building.
Code
Dear..Mr Gaynor
This letter is anAnstrument of record td cronPi telephone conver
sation of January 18, 1962'cb the above subject. .Mr. Gayno as you Ertl] remember,
our telephone conversation revolved =around the. minimum requi nits of-the height
of, structural •'Wod members;aho finich,grade; that•is;, Sect 805.,(x)'of'the'.
' i7niforin Building Code ststes`in'psrt that?•f tion walls supp, ng wood shall`:
extend at least-six inches above the. finish. adjacent to the wall at all
points:
This office) is dell aware t,, inmost es s, the new home comer,; in
landscaping his, yrerd; brings these -up,,'to;the top oP the.soleplate.for his
"aew flower beds.'=<Za doing this act-o moving'the earth,to'this elevation, he,.
does not, realize that r floErer, beds appraximatelj two inches higher-than -
.1-4 Aiiish• floor; part ly Por„hceies 'constructed on concrete slab. floors.., The end-'result often t ie that;ritgisture:enters,the ikl] and' onto floors
+ _ causing: damage ta,Purnis s; ;wet.-walls, peeling paint, `and' mold 621. Pram
&ins.or watering`of the,p ts,and lawns,•:etc: %Alt above mentioned damage
could_ be`eliminated`iP ttie proper, grading oP:the„earC. to`its finish level _
around all;outkde wol.ltfoiindation6 hadubeen.performed ,either ,by the contractor
or the: coiner. : , 1
Since our-telephone conversation as mentioned previous, this office has,
received a,letter .from a,Mr. Roy A,; Steckmesser whose.home is located at 3030
Country Club ,Drive. ., In hid letter to this4office,, he ,statei` that his Tloor ,
level and:the ground level is in•violation"of;the minimum;six inch grading
clause as set forth in.the'UniPorm Building Code:
Mr. Gaynor; he a businessman in-,the construction- field,-,I know that ~
YOU have';many;problems,to„solve x0kng`this, I.am4confident that.you;trlll
solve this knotty_,problem•of grading to'the satisfaction of all concerned.
=Respectfully yovrsi
MICiiAII.. B330 M
Building•Official .
MB:dh, ; - 4
January 19; 1962
City of Costa Mesa
Costa Mesa, California
Attention: Mr. Michael Bingham
Chief Building -Inspector
. 4 t
Gentlemen:'"
This letter. is to bring to your attention, as a matter
of record, .a violation of -the, Costa Mesa Building Code
concerning our home, 3080 Country Club Drive, built by
Jamaica Construction Company. The violation is in
regard to the 6" minimum between the floor level and
the ground level allowed by the building code.
On January 12, 1962; your City Inspector, Mr. Horicks,
inspected the residence and agreed Jamaica Construction
Company is in violation. He so informed Mr. McAllister
of the Jamaica Construction Company at this time.
On January 18, 1962, discussion with Mr. W Gaynor of
Jamaica Construction Company and Mrs. Roy Steckmesser
resulted in Mr. Gaynor's refusal to do anything further.
Also, it resulted in an offer by Mr. Gaynor to repur-
chase the home.
Our main interest, of course, is to protect our invest-
ment and to protect the life of the house. However, we
will accept Mr. Gaynor's offer to re -purchase the house
provided he assumes the existing loan; pays us $12,454.00
difference.;_.plus:$5000.00 for.nuisance; mental anxieties,
and inconvenience caused by this existing condition - -
total cash payment to us in the amount of.$17,454.00.
Further provision of,the transaction includes payment of
all transfer costs by Jamaica Construction Company, close
of escrow by March 1, 1962 provided the amount of $17,454.00
is paid to us ten days prior to close of escrow.
We would appreciate.your exercising the authority of your
office to correct this situation.
Ve
rytruly yours,
Steckmesser
3080 Country Club Drive
Costa Mesa, California
CC: Mr. W. Gaynor
Jamaica Construction Co.
&STA MESA BUILDING•SAFETY DEPARTMENT
P. O. BOX 817 COSTA MESA. CALIFORNIA
For Applicant to Fill In Completely
TYPE OR PRINT
BUILDING
ADDRESS 3080 Country Club Drive
COSTA MESA. CALIFORNIA
IFEE RE'C'EIVED
FINANCE DEPS:
CITY OF COSTA MESA
APPLICATION FOR PERMIT
BUILDING
For Office Use Only
OWNER Jamaica Construction Co
RECEIPT NO. PERM T N�
// o`
MAIL
ADDRESS 120 Bermuda Driv
RECEIVED BY DATE RECEIVED DATE IEEUED
- / -60 APR p 79en
_
7
C� TEL.
Costa Mesa
QSOTg
BUILDING
CITY NO.
ADDRESS
oR ENGi EEKenned & HudsonNo. OUlOS
COSTA MESA.
CALIFORNIA
ADDRESS Q Q
FIRE
ZONE TYPE
GROUP V"
�p�_
CONTRACTOR --
APPROVED
BY
DATE
3120 Bermuda Drive
ZONING
ADDRESS
Costa Mesa
ZONE
NO. OF
USE OF NEWP� �1--
CITY
PLANE
BUILDIN 1
STATE J TEL.
KI 5-9767
LEGAL
LIC. NO. -V0186 D.
DESCRIPTION
SIZE OF LOT p o
NO.
NOWT V
T N
A. P. NO.
l Tie 3
USE OF
YARDS
EVES
EXISTING BLDG.
APPROVED
ALLOWED
SETBACK LINE FROM 501 6�
(CENTER LINE ST.)
CENTER OP STREETREAR
FRONT
FT. IN.
`
I
SIDE YARD LEFT
RIGHTR.
SIDE
Q FT. IN.
DESCRIPTION OF WOL.
SIDE
FT. IN.
NEW I X IIALTERATION
ADDREAR
LS FT. IN.ii11REPAIR
MOVING
DEMI
APPROVEDI DATE / -(J VBUILDING
NO. OFSIZE
96.
_1 D
ROOMS 'SEXTERIOR
W ROOF •�COVERING
COVERING
USE OF BUILDING AND WORK TO BE PERFOR1
F Pe+
Ct�i
HEREBY ACKNOWLEDGE THAT 1 HAVE READ THICATION
THE AMOUNT SHOWN
UNDER VALUATION IS FOR THE
AND STATE THAT THE ABOVE IS CORRECT AND O COM -
PURPOSE OF EETABLIBHING
A PERMIT FEE ONLY.
PLY WITH AL CITY ORDINANCES AND STATE LAULATING
SUILDINNATU O BCnON-
VALUATION
SIGNATURE
PERMIT FEE $
_
SO
PERMITTE
�' / _ �J
-V S
$ !f O •
PLAN CHECK $ 07-0-
i
AUTHORIZED AG
TOTAL FEE
CITY OF COSTA MESA
BUILDING DIVISION
ROOF COVERING CERTIFICATION
Permit No. A"�O Q /2C�
Property Address CnUV\An j cku/ o 1--)r- C's401y\A s C_
Owner SC�►W����r�A �Y.e
Contractor A�/ o A/ aQ 6 _n e_Y11j `cx S
State Contractor License Number %71q Classification
I hereby certify that I have installed, or caused to be installed, a minimum Class C roof covering at the
above address in conformance with Chapter 15, and Appendix 15 of the latest adopted edition of the Uniform
Building Code, and the installation instructions of the manufacturer.
❑ I further certify that I am the owner of the property. (Owner -Builder permittee only).
I further certify that I am:
D' Owner of sole proprietorship company
❑ Full partner of the company
❑ Limited partner of the company
❑ Officer of the corporation
I certify that as an authorized officer or agent of the company or corporation, I am empowered to make this
certification, which shall be binding on all successors or assigns of the company or corporation.
I shall deliver a copy of this Certification to the above listed owner, after submittal of form to the Building
Division for acceptance.
Received by Building Division
By:
0980.46 MW 6/00 White - Building Div.; Canary - Contractor; Pink - Owner
Company or Corporate Name
IT70- 14- d
Address
_-
Signature Date
wo6
Printed or Typed Name
1112 s
I ial
Date
0980.46 MW 6/00 White - Building Div.; Canary - Contractor; Pink - Owner
Company or Corporate Name
IT70- 14- d
Address
_-
Signature Date
wo6
Printed or Typed Name