HomeMy WebLinkAbout192 ALBERT PL - Building Permits OWNER DT�l 5 , w it O DATE 2-li-57
JOB ADDRESS 192 E; Albert Place BUILDING PERMIT NO. #k271
GENERAL CONTRACTOR Armadge, Inc. VALUE $ 7,320.00
AP118-084-07 -
L 55 BLOCK TRACT ilk Res. w/att. gar.
GROUP I & J TYPE V ZONE Rh FIRE DISTRICT 4340
INSPECTIONS DATE SUBCONTRACTOR PERMITS ISSUED
DATE . NUMBER
Footing Trench tt,• 44--4 a -/7 JP'
Foundation Forms and Grade to Garage,!y
Rough Framing ( l it - /31
Plumbing, Rough to Slab in(°- ej a-/y-S7
Plumbing, Rough Complete {'YI e5 ,$-J-s-7 [ /- L '" Jr a - 6-S 7 5 n
/ -2_,
Temporary Pole
Wiring, Rough MAR 1 i ' ' ' ' in, l _ /_ : 2 ' - 7-..7 QO 7[/
Heating,Rough Jn iv sj.,,I -f-S'7 ,�.,,// --,4 /77
Heating, Final ?- -?' -6 l/fl -/r'_ /^./. a -4 -S 2 _ 7J/.Z —
/Sewer, House `/iL Sewer,St. Yry,GS ti,/2,,J-7 U l.vYl,t, -v-1/--S 7 e9 7 6 --
Septic Tank or,}Cesspool �O ,r/ /
L ig, In ( 4.r Out {-/I- I- y / -.
Plastering d (f r 7r ..0 /- - 6,41 Jt ' {14,r. y-17-,1"7
Plumbing,Final,Fixtures Complete e$ -2..,$=.57 , ' r •-As_.A N-/7-6 / 70". V — '
Plumbing,Final Gas Test /.S-"P4 Kite", - , .$ - ,1,_ - ..„y 44.4 -CCr 4 G Com/ \\
Wiring,Final APR 2 ' 1957 VCB )"ir ;�j� _ ,��"!!"-' V
Occupancy *39-57 \
FORM 210 3M 10.55 11271
PROJECT ADDRESS: 192 ALBERT PL UNIT: CITY OF COSTA MESA - BUILDING PERMIT PERM NO; B 05033
OWNER'S NAME: DARREL A LIGHTNER
ADDRESS: SAME PERMIT NO: B 050333 PLAN CHECK NO: 05395-90 S GOVT: N SUPP: N
CONSTRUCTION TYPE: PERMIT TYPE: STR PURPOSE: ADD
650-3563
;tw1RCHIENGINEER: REG.NO.: JOB DESCRIPTION ; 132SF RESIDENTIAL ROOM ADDITION SQ FT: 132
ADDRESS: UNIT:
CLAIM VALUE: 7,000 . 00 CALC-VALUE: 9, 108 .00 GROUP OCC: R-3 /
. PERMITTEE: DARREL LIGHTNER ( 714 ) 650-3563
ADDRESS: 192 ALBERT PL COMMENTS: X
C.M. CA 92626 ********4***************x***;eye*************************+FyEyE******************Tt**
LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section Z ONING REQUIREMENTS
7000)of Division 3 of the Business and Professions Code.and my license is in full force and effect. SETBACKS
CITY LIC.: STATE LIC.: CLASS:
Dale: ! Signature MAIN BUILDING ACCESSORY BUILDING ---------
WORKERS'COMPENSATION DECLARATION: hereby affirm that I have a certificate of consent to self-insure or a certificate of Workers' FRNT: 34 FT IN REAR: 10 FT IN FRNT,: 10 FT IN REAR: 18 FT I N
Compensation Insurance.or a certified copy thereof(Section 3800.Lab. C). LEFT: 5 FT IN RGHT: 23 FT IN LEFT; 6 FT IN RGHT: 8 FT IN
POLICY NO.: EXP.DATE:
'COMPANY: PARKING RE 4 PROV• PARCEL: 00000000 INE; R2
REF NO:
Certified copy is hereby furnished. ❑ Certified copy is Med with the city Building Division. PLANNING NOTES> FOR A 132 SQ. FT, BEDTOOM EXTENSION, ONLY.
>
Date: Applicant: ***-1i**************************************IE********************!F**************#E
EXEMPTION FROM WORKERS'COMPENSATION DECLARATION: (This se ion need not be mpleted if the permit is for one hundred($100)or less). DEVELOPMENT SERVICES REQUIREMENTS
I certify that in the dorm nce of the work for which this permit i ue I shall employ any person in any manner so as to become
subject to the Wo ers' (�9,p�e7nsation Law of California. ZONING APPROVED BY Co. (sr
DATE: 1 L I `-j o
Dale: / �7�/w you 4ifte /
NOTICE: f.after making this declaration,you should become subject t Workers'Compensation provisions of the Labor BUILDING APPROVED B Y DATE: �r p
Code.you must forthwith comply with such provisionsrthat or this permit be deemed revoked. S A DATE• 2— I I 1 .7.
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for APPLICATION ISSUED BY• iF 3F WWW***ii
which this permit is issued(Section 3097.Civ.C). *******************************************************Tt*********IE*** ****
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 117 . 00 , 64
repair any structure,prior to its issuance.also requires the applicant for such permit to fife a signed statement that he/she is licensed SMI P/NON-,RES
pursuant to the provisions of the Contractors'State License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business
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 76 . 05
any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars(5500). ISSUE FEE
I, as owner of the properly or my employees with wages as their sole compensation, wig do the work, and the BUILDING-D IV-> PERMIT ISSUE PLAN-CHECK TOTAL PAID' DUE
® structure is not intended or offered for sale(Section 7044.Business and Professional Code: The Contractors'State License Law TOTALS----> 117. 64 0 . 00 76. 05 193 . 69 193 .'69, . 00
does not apply to an owner of a property who builds or improves thereon,and who does such work himself/herself 0l through
his or her own employees, provided that such improvements are not intended or offered for sale. If, however the building or REVENUE DIVISION IVIS ION TOTALS--> COLLECTED• 117. 6 4 OVER/SHORT• 00
r improvement is sold within one year of completion,the owner will have the burden of proving ateshe did not build or improve
for the purpose Disale). 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
117. 00 64 ' '
❑ and Professions Code: The Contractors'State License Law does not apply to an owner of propert who builds or improves thereon •
and who contracts for such projects with a contractor(s)license pursuant to the Contractors' License Law).l am aware *******************************************************************************
that proof of their Worker's Compensation insurance should be provided to me. INDIVIDUAL F E E BREAKDOWN '
❑ I am exempt under Section: B. 8 P.C-
formisreason TYPE QTY DESCRIPTIO N UNIT COST TOTAL COST
(
Dale: %7/ /Sa ' Owner�L[/ 164CSFR 132 DWE-TYPE V-WOOD FRAME -GOOD 69 . 00 9, 108 . 00
I do hereby cenif that I am aware of and understand the requirements of California Health a S ety Code Sections 25505,25533,and
1;
♦ END OF FEES
• 25534 and that I or any future building occupant will/will not(circle one)need to comply with ' state codes and the requirements for a
permit for construction or modification from the Air Quality Management District.Residential construction applications are exempt from f E1
these provisions. EXPIRED
Dale: Applicant' Incomplete Inspections
I hereby certify that I have read this application and state that I Bove infarmatiot correct.I agree to comply with all city antl ounty \A\
ordinances and state laws relating to buildin onutructlon and authorize rep tatives of this,city to enter upon the above m tinned r•" A /
property finsor ectio purposes. / / Date _ Sig_ kDale: 7 90 Signature' _ 010DG7540r:-�.L"16�C; ?-L�+7 + ''Driver's license or social security e: NO4931O2ADATE: 12/17/90 TINE: I4:0c
Ilk1641-46 White—Building;Green—Code Enforcement,Canary—Ap•i Pink—Revenue',Goldenrod—Assessor 1
II
CONSTReCTION AND PLANNING POt SPA
APPROVALS Permit # Date Inspector APPROVALS Permit # Date Inspector
1. Temporary Electrical Service or Pole 52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement
3. .Electrical Conduit Utility-Undrgrnd. 54. Forms
• 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding
5. Steel Reinforcement 56. Rough Plumbing & Pressure Test
• 6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE
7. Footings 58. Electrical Conduit-Undrgrnd. ..
8. Foundation 59. Gas Pipe, 0 Undrgrnd.,Test
9. Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap, Y'Undrgrnd.
10. Structural Floor System - 61. APPROVAL TO DECK
11. Property Sewer Line & House Connection . - 62. Backwash & Receptor-Final....
12. Sewer Cap . 63. Heater & Vent-Final
13. Roof Drains • 64. Plumbing System - Final
14. Rough Plumbing 65. Electrical-Final • `
15. Rough Electrical-Conduit 66. Solar System-Final e
16. Rough Electric Wiring 67. Fencing & Access Approval
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 Factor-y Fireplace ; APPROVALS -Permit# -
21..Ducts,in Structure. • - 70. Underground.Hydro
22. Ducts, Ventilating , - -71. Product Piping 0 Gas 0 Oil -. -
23.,Gas Pipe-Rough & Test , 72. Underground Flush:
24. Roof Framing - - 73.-Undergrnd.Storage Tank 0 Gas 0 Oil
25. Roof Sheathing _ = ., . 74.-Overhead Hydro
26.-T-Bar Ceiling (Structural) & Monocoat - 75.. Dry Chemical
27.-Frame and Flashing ' - 76. Dry Standpipe -
28. Lathing & Siding • -- 77. FIXED SYSTEM FINAL - `.T
29. Insulation , 71-7
1 ' I.I. . 78.- FIRE PREY FINAL
30. Drywall Nailrng - - 1 1, ' HEALTH DEPT. REQUIREMENT '
-_31. Plaster Brown Coat. , I , _ .79. FINAL INSPECTION -
32. Electrical Power Meter-Final. I 80.+FOOD CERTIFICATE ISSUED -
33.,'Final Electric I ' . 'Notes:
.
34.- Final Heating & Air:Conditioning-, -35.-Final Gas Gas Pipe-Test ' - - -
1 -
,36. Hood or Canopy . -.
37. Final Factory Fireplace, '
38. Final Plumbing - F
:39. Water Service-Final -
40. Gas Service-Final , •
41. Solar Domestic-Final - - - -
42. Backflow Preventer. I I ii.• ;- -
•43. Backflow Irrigation - - '
44. Landscape Irrigation System , • - _ - -
45. Sound Attenuation - - - - 'i
46. Handicap Regulations C x P R E D.
' Incom tete Inspections
47. FINAL STRUCTURE & BUILDING
48. FINAL PLANNING
_'_s�Or
-49. Electric Release to Edison - - j
50. Gas Release to Southern California Gas Co ° :. � -
51. CERTIFICATE OF OCCUPANCY
No. Date
PROJECT ADDRESS: 192 ALBERT PL UNIT: CITY OF COSTA MESA — BUILDING PERMIT PERM NO: E 049082
OWNERS NAME: DARRELL A. LIGHTNER
ADDRESS: 237 CANAL PERMIT NO: E G49082 PLAN CHECK NO: N GOVT: N SUPP : N
NEWPORT BEACH
CA 92663 CONSTRUCTION TYPE: 5—N PERMIT TYPE: ELE PURPOSE: OTH
( 714 ) 675-7450
' ARCH/ENGINEER: REG.NO.: JOB DESCRIPTION : UPGRADE EXISTING ELEC . SERVICE TO 100AMP SQ FT :
ADDRESS: UNIT:
CLAIM VALUE: CALC—VALUE: GROUP OCC : R-3 /I!-1
PERMITTEE: DARRELL A. LIGHTNER ( 714 ) 675-7450
ADDRESS: 237 CANAL COMMENTS : **********************3**********-***ft***
NEWPORT BEACH CA 92663 **************************************************************** ************;;
LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section Z ON ING REQUIREMENTS
7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect. SETBACKS
CITY LIC.: STATE LIC.: CLASS:
Date: Signature: MAIN BUILDING -. ACCESSORY BUILDING •———— —-——-
WORKERS'COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self-insure or a certificate at 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 RGHT: FT IN LEFT: FT IN RGHT: FT IN
POLICY NO.: EXP.DATE: •
1MPANY: PARKING REQ: PROV: PARCEL : 00000000 ZNE: REF NO:
Certified copy is hereby fumished. El Certified copy is filed with the city Building Division. PLANNING NOTES>
>
Date: Applicant: ******************************************************************************a:
EXEMPTION FROM WORKERS'COMPENSATION DECLARATION: (This section need not be completed if the permit is for one hundred(5100)or less). DEVELOPMENT SERVICES REQUIREMENTS
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. ZONING APPROVED BY _ DATE:
Date: Signature:
NOTICE:If,after making this declaration,you should become subject to the Workers'Compensation provisions of the Labor BUILDING APPROVED BY . _ _ _ - DATE:
Code,you must forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for APPLICATION ISSUED BY : DATE : 9- z b -pd
which this permit is issued(Section 3097,Civ.C). **********************f,.,t *#,a• ; £. .' .*3!;F" -. sr..4 / ,o#*iFrxF***************;.**ie•****x4 **
LENDER: • **********************************w****** .**e' **************Y,**************et*Y.0*
ADDRESS: LEGALIZATION:N F E E S U M , A R Y STRUCTURAL SEGMENT: N
OWNEMBUILDER 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 PERMIT 1 8 . 5 0 ri
repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he/she is licensed
pursuant to the provisions of the Contractors'State License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business -+0 X S M 1'P/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
any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500). ISSUE FEE 1500, -
I, as owner of the property or my employees with wages as their sole compensation, win do the work, and the
BUILD ING—D IV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID .. DUE
❑ structure is not intended or offered for sale(Section 7044,Business and Professional Code: The Contractors'State License Law TOTALS----> 18 . 50 15 . 00 0 . 00 33 . 50 3 3 . 5 0' . 00
does not apply to an owner of a property who builds or improves thereon,and who does such work himself/herself or through , ----
his or her on employees,provided thatsuph improvements are not tbddeofrpd for sale. If,however the bui
lding or
improvement
rohmot issold within one ear of completion,oveasr will have the burden of provinghe/she did not build or mnr o REVENUE DIVISION TOTALS--> COLLECTED : 33 . 50 OVER/SHORT: --, •
. 00
for the 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 33 . 50 •.—
❑ and Professions Code: The Contractors'State License Law does not.apply to an owner of property who builds or improves thereon 1
and who contracts for such projects with acontractor(s)license pursuant to the Contractors'State License Law).l am aware ************************!.-*****************************************je*#^Iflf*********
that proof of their Worker's Compensation insurance should be provided to me. INDIVIDUAL F E E BREAKDOWN `
0 I am exempt under Section:B p 7044 B.IS P.C.
for this reason: ALL WORK BY OWNER. / / TYPE QTY DESCR IP T ION UNIT COST _ TOTAL COST
Date: — Q Owner n" // `t
9- �� ! D ELE 1 SERVICES BELOW 600 V & BELOW 201 AMP 18 . 5018 . 50
I do hereby certify that l am aware of and understand the requirements of California Health and Safety Co. actions 25505,25533,and
•
25534 and that I or any future building occupant will/will not(circle one)need to comply with said state . s and the requirements for a i. END OF FEES yL
permit for construction or modification from the Air Duality Management District.Residential constructi.' applications are exempt from 'j,Ej
these provisions. •
Date: Applicant: - EXPIRED
I hereby certify that I have read this application and state that the above information is correct.I agree I. i ply with all city and county Incomplete Inspections..
ordinances and state laws relating to building construction and here
..�q rue representatives/esof this 0 er upon the above-mentioned / ., - . - — • • /
property for inspection purposes. /^ Nma Date -` --.— .Sig 8'-1} ..., � -a. i: .::� 1 ,
Date: 9 O Signature:
Driver's License or Social Security#:
/
164146 White—Building;Green—Code Enforcement;Canary—Applicant;Pink—Revenue;Goldenrod—Assessor 4
911111F___
CONSTRUCTION AND PLANNING PC SPA
APPROVALS Permit# Date Inspector APPROVALS Permit # Date Inspector
1. Temporary Electrical Service or Pole 52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement
3. Electrical Conduit Utility-Undrgrnd. 54. Forms
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 59. Gas Pipe,0 Undrgrnd.,Test ., .
9. Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap, ❑ Undrgrnd.
10. Structural Floor System 61. APPROVAL TO DECK
11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final
12. Sewer Cap 63. Heater & Vent-Final
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
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 ❑Gas 0 Oil
23. Gas Pipe-Rough & Test 72. Underground Flush
24. Roof Framing 73. Undergrnd.Storage Tank 0 Gas 0 Oil
25. Roof Sheathing 74. Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical
27. Frame and Flashing 76. Dry Standpipe
28. Lathing& Siding 77. FIXED SYSTEM FINAL • '
29. Insulation ,%. 78. FIRE PREV. FINAL T
30. Drywall Nailing HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat 79. FINAL INSPECTION •
- -
32. Electrical Power Meter-Final / 80. FOOD CERTIFICATE ISSUED
33. Final Electric ft Notes:
34. Final Heating & Air Conditioning - �
35. Final Gas Pipe-Test
36. Hood or Canopy
37. Final Factory Fireplace
38. Final Plumbing
39. Water Service-Final
40. Gas Service-Final
41. Solar Domestic-Final
42. Backflow Preventer
43. Backflow Irrigation
_ tt
44. Landscape Irrigation System d ,
45. Sound AttenuationE X p ( R E D
46. Handicap Regulations tncofP, to %nypeCt'OnS
47. FINAL STRUCTURE & BUILDING
48. FINAL PLANNING 1J8te
49. Electric Release to Edison
50. Gas Release to Southern California Gas Co
51. CERTIFICATE OF OCCUPANCY
No. Date
-...c•-•,-‘4....'i— 4340 7 3 0 6 0 g.
COSTA MESA BUILDING DEPARTMENT
P.O. BOX 317
COSTA MESA. CALIFORNIA
FOR APPLICANT TO FILL IN APPLICATION FOR PERMIT
L• RDEI ;L /111_,,,,/ ad..„ e 111 . BUILDING
f COSTA MESA. CALIFORNIA FOR OFFICE USE ONLY
// D RECEIPT NO. �{PERMIT NO.
OWNER/Il; Al....,..„ 4, ` � / /
MAIL LL j U/�/` RECEIVED BY. )DATE RECEIVED 0.9-,, -3-7
`f DATE ISSUED
ADDRESS / 0 �- . t a,.., .E:�C� -�J�/�i/ /� . 1'Cr7 .^ — -3
• Ca Jj - P4,14
4 ''// NO. ABUILDIDDRESS
41.,2,---.796• Xr! NO. ADDRESS
ARCHITECT 4 LIC.
• ENGINEER ENTINTER NO.
COSTA MESA. CALIFORNIA
FIRE
ADDRESS ZONE
ZONE NO.NS TYPE 1 / OROU
CITY LIC. � , PLANS
J
CONTRACT/OJR7 /1 46( ,Z (�//jp}.0/,/( (1 NO. �y ( v, I/y 1 C�'�{/l i�
ADDRESS/ 7 A �/� �{ t-�(F-•!yy/)II, TEL.
NO I /yy7I APPROVED � ! /+ E�_ ( V)
LEGAL LOT .� '�J / f l `l�1(f �"
DESCRIPTION NO. 1/4a BLOCK// / TRAOT/15 A h, p
A.P.NO. /l e -- C) c 7 CJ 7 Ci TY OF rOSTA MESA.,
OSIZE F LOT,4:.:2/ )( /$'& NO. ON LOTS' / PLANNING DEPT.
USE OF / •�' r
EXISTING BLDG. + CJGi /[,�'�(� L
/ /
SETBACK LINE STREET ��L-/1 REAR YARD .2 RYA -DATE /-37--5 7
CENTER OF `�/ � �f 'µ',j�(��{�'I
SIDE YARD RIGHT / / LEFT `p ` /el) e.tJtl ,—
DESCRIPTION OF WORK
NEW ALTERATION ADDITION
REPAIR v ��MOVING ry DEMOLISH
BUILDING �u 2 1-wd_t NO.OF
SIZE ��. '
'c1 P'� ROOMS STORIES
EXTERIOR WA 0I. / ROOF '�
COVERING //////111111.LLTA//"i(% COVERING(04.--b/vv/V1 ..
USE OF NEW wE-1 q •Ity • LI�'i
BUILDINGN (( t
a CP,CE7 s'CA /A- . 0
c2�oo .
--
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND
STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL
CITY ORDINANCES AND STATE LAWS REGU TING BUILDING CONSTRUC-
TION. y///� //J /I t / VALUATION
SIGNATURE PERMITTEE OA��4�S • L.V 1•...z.. A, PERMIT FEE S ,/�O/
z 3 �0 PLAN CHECK 5 / O
AUTHORIZED AGENT ' TOTAL FEE $ 3 o —I ‘Ipb