HomeMy WebLinkAbout3042 BABB ST - Building Permits(714) 754-5273 • Fax (774) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
BUILDING PERMIT
Job Address: 3042 BABB ST
Suite:
Vicinity: ROOF
Parcel Number: 41808102
Applicant: KELLY WILLIAMS
Address: 613 SHASTA LN
COSTA MESA, CA
Owner: MOORE, HOMER G
Address 3042 BABB ST
COSTA MESA, CA
Contractor: ALL COAST ROOFING
Address: 613 SHASTA LN
COSTA MESA, CA
Zip: 92626
Arch :
Address:
Zoning:
Phone: (714)444-1�11
Zip: 92626
Phone:
Zip: 92626
Phone: (714)444-'1111
License: 598440
Eng:
Address:
ISSUED BV:
Status: ISSUED
Applied: 11/01/2004
Issued: 11/01/2004�
Phone: Phone:
Zip: License: License:
SCOPE OF PERMIT
TEAR OFF EXISTING ROOF. INSTALL 1/2" OSB SHEATHING, FELT, 30 YEAR FIBERGLASS SHINGLES. 25 SQUARES INCLUDES ATTACHED ,
GARAGE.
Plan Check: $0.00
Permit: $125.25
SMIP Res: $0.60
SMIP Com: $0.00
Other: $0.00
Inspection: $0.00
Total: $125.85
SETBACKS
MAINSTRUCTURE Front 0-0
ACCESSORY Front 0- 0
PARKING Existinq: o
Rear 0-0
Rear 0- 0
Required: 0
FEE SUMMARY
PLANNING & ZONING
Left 0- 0
Left 0- 0
Proposed: 0
Calc Valuation:
Claim Valuation:
Right 0- 0
Right 0- 0
ss,000.00
Ss,000.00
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, 1241-92) .
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 ihe work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
� requlred Inspectiona and flnal approval must be obtalned. Failure to obtain inspections and final approval will result in ihe expiretion of this permit.
FOR INSPECTIONS CALL: (714) 7545626
�aasaa ldoo�
WORKERS'COMPENSAnON DECLARAnON: � , . � �
I hereby eHirm under penalry of perjury one of tha following declarations: � '
❑ I have and will maimein a certificate ot consent to seH-Insure for workers' compensetion, as providetl for by section 3700 of the Labor Code, for the peAormenca of ihe
work tor w�ich ihis permit is issued. .
�'Qj 1 have entl will meintain workers' compensation insurance, as repuiretl by section 3700 of the Labor Code, for Ihe pedormance of Ne work for which �his pertnit is issued.
My workersc' o_�o��npeqsation Insu�ce .c.aNrrjer antl poilcy number are: � ^ �
Carrier: �]iPn� i\`, Policy Number: d �� I��— rAUO LI
(This section need not be completed i/ ihe permit is valuetl et one hundretl tlollars ($100) or less.) ,_ „
❑ I cetlify ihat in ihe pertormance of the work for which ihis permit is issued, I shall no� employ eny person in eny manner so as to become su6ject to ihe workers'
compensation laws ot California, antl egree that If I should become subject to [he workers' compensation provisions of Section 3700 of Ihe Labor Cotle, I shall forthwith
comply with ihese provi ns. ' I
Applicent Signeture: �g��^_. L��...�Q �%-c� Deta: �� i.� ��
WARNING: FAILURE TO SECURE WOPKERS' MPENSATION COVERAGE IS UNLAWFUL ANO SHALL SUBJECT AN EMPLOVER TO CRIMINAL PENALTIE AND CIVIL FINES �P TOONE HUNDRED
TFIOUSAND DOLLARE (5100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDE� F-0R IN SECiION 31060F TME LABOR CODE, IMEREST, AND ATTORNE`fS FEES.
LICENSED CONTRACTORS DECLARATION:
1 hereby aHirtn that I am licensed untlgr p,�oyysi<
force and ettect. Lic. #
Contrector's Signeture:�
Chapter 9(commencing wilh Section 7000) of Division 3 of the Business and Professions Code, and my license is in tull
d� ClessN e-�R
1_..R_Ro Date: � I- I� O�l
CONSTRUCTION LENDING AGENCV:
❑ I hereby aflirm ihat there is e constmction lending agency for ihe pedormance of ihe work for which ihis permit is issued. (Sec. 3097, Civil Cotle).
Lenders Name: Lendar's Address:
SignaNre:
OWNER•BUILDER DECLARATIONS:
Date:
I herehy aNirtn that untler penalty of perjury Ihet I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for Iha tollowing reason (Sec. 7031.5, Business end Professions
Cotla: Any city or county which reQuires e permit to constmct, alter, improve, demolish, or repair any stmcNre, prior to its issuance, elso requires the applicant for such permil
to tile a signed statement that he or she is licensed pursuant to ihe provisions of the Contractors License Law (Chapter 9(commencing with Section 7000) of Division 3 of Ihe
Business antl Professions Code) or ihat he or sha is exempt theretrom and the basis lor Ihe alleged ezemption. Any violetion of Section 7031.5 by eny applicam for a permlt
subjacts ihe epplicant to e civil penalry of not more than five hundred tlollars ($500).):
❑ I, as owner of the propeny, or my employaes with weges as their sole compensetion, WILL DO THE WORK, antl iha stmcWre is not intentletl or oNered for sale (Sac.
7044, Business antl Professions Code: The Coniractors License Law tloes not apply to an owner of propeny who builds or improves thereon, and who does such work
himselt or herself or through his or her own employees, provitled Ihat such improvements ara not intended or otteretl for sale. If, however, ihe building or improvement is
sold within one year of completion, the ownar-builder will have ihe burden of proving that he or she did not build or improve for purpose ot sele.). '
❑ I, as owner of the property, em EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to consiruct the project (Sec. 7044, Business antl Profassions
Code: The contrectors License Lew tloes not apply to an owner oi propeny who builtls or improves thereon, antl who contracts br such project with a contrector(s)
license pursuant to the Coniractors License Laws.).
❑ I am eaempt untler sec. Business and Professions Cotle for this reason:
Signature: Date:
Owner ID verified by tlnver's license. ❑ Yes ❑ No Driver's License No. Expires:
Veritication ot Ownarship by (rype of document, i.a. - proparty tax bill or deed):
DIVISION OF INDUS7RIAL SAFE7Y PERMIT CERTIFICATION:
❑ I hereby cetlih/ thai no axcavation five (5) or more feet in depih into which e person is required to tlescenq will be made in connection wi�h work authorized by Ihis
permit, and ihat no building structure, scaHoltling, falsework, or tlemolition or dismantling ihereot, will he more than thirty-siz (36) feet high. (Chap. 3.2, Grp 2, ArI 2, Sec.
341, Title 8, Calitomia Administrative Code).
❑ As owneo-builtler, I will not employ anyone to do work which would require a permit from the Division of Industrial Satety, as notetl ebove, unless such person hes e
permit to do such work irom the division.
SignaWre: Date:
Division ot Indusirial Safety Permit Numbar:
CERTIFlCATE OF COMPIJANCE AND AUfHORIZATON OF ENTAY: I certify untler penalty of perjury ihat I have read this epplication antl state that ihe information given is
correct. I agree to comply with all state laws and ciry ordinances relating to Duilding conswction, and authorize representatives of Ihe Ciry ot Costa Mesa to enter upon Ihe
above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authonzed by ihis permit un�il tinal inspection.
� � ,�qnatute Of Legel Owner(s) i `� � �'
�,y� .-t���
And/OrAuthorized Applicent Dat
CQOE I, INSPECTONTYiE
1616 Fixetl System Final Fire Prevention
t�Pool Spa Final
200 Final Re-Root
201 Final BIocWRetelning Well
202 Final Factory Fire Place
203 Finel Sign
204 Final Demolition
eeie
COUE I INSPECTION TYPE
206 Final Mechanical
20B Final Plumhing
210 Final Elecirical
212 Final Flre Prevention
220 Final Planning Approval
222 Final Site
250 Final Builtling/Occupancy
PAIE It�Id15
wowEssaew�ow� 3U92 bAbB ST
OMNEP'SNMIEIFRMWN: MVl7RE, HOMER G
A0D"�' 3092 BABB ST
CGSTA MES7�, CA
�vv�. Yuuac �oowess:
APCNRECT OX FM]NFEP:
��:
FLOUD: X 97
92626
uc. xo:
UM:
C01^""C0R5N"'E NOCK PLUMBING ( 714 ) 895-1246
CpRPACTWt5YY11N0 1 1 6 1 2 KNOTT S T
wonEss �,ARLEN GROVE CA °0'N0'` 707775
92891 uNT 17
L ED COMF1CTOflS DEC WflATION: I Mreby eflim uMer panely d peijury Ihm I em IcereeE uMm prowbna ot CMper 9
m tlnB �h Sec�ion ]000) M DiWebn 3 W �ha Businen enE Profesaiana Coda, ud my lioenae is in tull brta end Med.
CffY U NO.: �F ClA3S: 11C. NO.:
0503� C-36 707775 EXP: 02/98
�o�„�a:;.tc,t� p�Um ,..k:
0 BUILDEN DECIARRTION: I he�eby dfiim uMer peraly d parjury thm I em examq Irom iM COM�etlas Licrose Lew la iM
'NloxmB reeeon (Satlion ]081.5 Bue'vreac enE Roleseiona Code: Any cIy a caunry whidi requirea e permil lo mnwcl, elix, improva,
�ioleh, or repe'r eny ewcture, pnor lo Ns vauence, elvo requirea Ihe epDliunt fw auch paimn to Rb e eqnad sletemaM tliel M or eM
ramed W��� lo IM pwiaons d IM Conlreean linme law ICheqr B(�mmaiq wnh Seaion ]OW) d OM6ian � d Ib
..�rb» eM Prdavurv CaEel a iM1tl he or aM ia memN Iherehom aM ihe besa lor IM elb0� memqion. MY videtion al Setlbn
�03t.5 by eny epplicent lor e permn eubpcls ��e eppl"ra�i lo e avil panelry d iwl more Ihen live hwMrad dd4n �SSOOj).
� I, m oxner d IM popany n my empbYem w�h wepee n iMi ede mmpenaetbn, will do tM wwk, vd Ihe avucWre u iw intaMeA
«Meretl In eeb (SecUan lwa. am�» eM PrdmaiansCoCe: The Conlrmas lioame law Ams nd eOWYto en ownra propeny
who buiEs a inpwee tMreon, eM wM1a doae auch work NmeNl a Mnatl «Mraph ha «her oxn empb�ese, pwided tAm aM
improvemenis ara mt imeMed a o/iered Im eale. tl, however. �M buiNi�q a impwamem ie edd wnhin are yaer d mmplwion, Ne
owror-0uiNar will Mve Ine buNen d povi�p he w eha did mt WiM or impraro la IM purpoee of ede).
� I. u owmr d the propany. am udirsrvely mntretliq wi�h Iittn�eE coMredas �o mnmrud tha poptl (Setlion ]OII. &ninma eM
Prolessione cada: TM comreclae Lcenae Lew daee �wl eVON lo en owner a YWaM wtu Wik. «'unP�'m ihaean uM xfio
contrecro M euch prqepe wi�h e ooniredor�a) lcaneed pureueni m tM Conlraaore Limrree lew�.
� I em eRemq urdar Sxtion: B. 8 P.C., fa Nn �aawn:
o�e: o�.�.,:
i eo nereer �N �ne� i em .�.�e w.�e �meen�ena mme �ea���.�a w cv�omm Heean a�d smmv coae s«+�. nws. zuv..�d
PSS1f. enE tla� I ar e�ry hnure WiMiip ocapeni will / wil nd (dicb me) neeL to campy wYh eeM elete oodo enE tM rtQu'uemanb br
e permn I«conslruclionw modifiralionhan�he Fi�augement Diatna. Raeidemiel wnatiueun eppFatiom eieaxemp Irom Ihme
yoviaiona.
oma: noWicem:
WORKER'S COYpENS�TION DKL�PATION: I hereby elfiim uMer panelly d peQury one d Ms tollowiip Esdvetiora:
❑ inaroe�ew�me�m.:�.�ennKmaammemm..n:�.er«.w�d:ca�vMw�.ma���Mseacnarooam.iee«
Code, fa Ihe paAarmarKe o11M �wrk f« which this peimn ie inued.
� I M<ad wil mainUn wwken' mmpenmlian inaurerce. m myuired by SeCion 31W d iM lebor Cods. tor tM psel«meme M IM
X work la whidi Mo D�� is uaued. MY waken' com0e�ion imu�arics farrier erd P�KY riumber ere:
c�e�: �r%�*� nrr� n EXF�IRES
PdicyNumbm: � 09/01/97
�rnis senan neee rrot na m,idmad r �ne v�R n b• � nundred doLers tao n rsv.1
I cenM �hel in �he pe�lamence W the wak 1« whch t�ie permil' eE. I ehell ral empby erry penon m ury menmr m m �o
become wbjeG lo ihe xoikme' mmpeneNion levn d Cel' eprae thet ' Id becoma wEjeif to IM v.orken'
ompevetun pa eiom �.B n 3)00 d iM Lebor Cade. I 1 t ' n cpnyy Up�e mri�une.
ome: Z1 �voi�:
e np: FaUun ro aecun waAari mmpwuetlon coveregs li unlewNl, �nJ �IWI Nb/sct �n rrployw ro aIMrW pwlllu uM
roi'q ro om �'nOrstl HauuM Jolkn (5100,POOA Mi atltl�tlon b tlro cwt o/ rompNuatbM1 tlamepss u provhNO M In
SwXon 9]O6 0/ Ihs Le6or Codr, /nbnst, and ettomey'a hu.
CONSTfiUCIION LENDINO �GENCY: I Iw�eby alfi�m �ma. w�.M a v�.Nrv �nm mere a.�a�a� w�d� m�.y �. m.
peripmarim d IM xak la whirh �he permi u uaueE (Sedion 9081, Civ. C�.
LENOEH'S NRME:
LENDEN'S ADOHE55:
I carlily Ihm I heve reeE Ihie apdwenm end pela iMl ihe ebova inlarmetion ia coried. I eprea lo canply v.iih ell ary uN camty adinerioee
end aieia lexs releiinB �o W iking cons4utliai eM hereby euthorize repesenimivea d ihie ary �a enter upon iM ebove�menlioneE poparry
1IX1119pBtl1011pllfp0%S.
ON N CK
vno eme �
Dme: �',
�'sie�d�,aW �ov vor aov m .
CZTY OF CGSTA MESA - BUILLING PERMZT
PEkMIT NO; P 089353 PLAN CHECK NO:
CONSTRUCTION TYPE: V-N PERMIT TYPE: PLU
JUB DESCRIPTION ; DISHWASHER C/OUT
fil
q%- b
F�ERM NU: F 08435"
GOVT: N SUPP: N
SQ FT:
PURPGSE: OTH
CLAIM VALUE: CALC-VALUE: GROUP t�CC; k-3 /
COMMENTS; NU OTHER WOkK ASSOCIATED WITH THIS PERMIT
��*���t����t*****�r*�;�*��r�r*�r�r�t�t*�***�***�t**�t�t;t�**,��t�**�r���t��r;�*�r*�;���r*�r*�r�t�x;��*���,�
Z O N I N G k E Q U I R E M E N T S
S E T B A C K S
------------ MAIN BOILDING ---------- --------- ACCES56RY BUILLING --------
FANT: FT IN REAR: FT IN FRNT: FT IN REAR; FT IN
LEFT: FT IN RGHT: FT IN LEFT: FT IN RGAT: FT IN
PARKING REp • PROV: PAftCEL: 41808102 ZNE; REF NO:
PLANNING NCiTES>
i '
�k i! iE ik iF iF if ik if iF iF if iE if iE iE iE if iE iF iE if iF if iF ie iF �E 1f if� 1k iE iF IE �E i! 1f ?E if 3E iE it ik iE iE �E jE'3f 3E �f 3e �E fE iPii-1F iE if ik jE iE iE iF �f �k �f iE i2 iE iF �lc 3E iE ik jE iF �E 3e iF
D E V E L O P M E N T S E R V I C E S: R E Q U I R E M E N T S
ZONING APPROVED BY ,
BUILDING APPROVED 5Y
APPLICATION ISSUED
�r*�t�r� �t*�t*� �t***�t*�r*�
LEGALIZATION:N
BLDG PMT
PERMIT
PLAN
ZSSUE FEE
BLIILDING-DIV->
TOTAL5---->
F E E S.0 M M A R Y
� i
PLUMBING ELECTRIC:'; MECHANIC FIRE
�.%S "
258 -
� �1
LATE:
DATE;
DATE: I �
if�1F aE �E�1E�1E jf jE x iFiE
STRUCTURAL SEGMENT:N
SMIP/RES GRADING
SMIP/NON-RES
2 2 , � � '
PERMIT ISSUE PLAN-CHECK TOTAL PAID DUE
8.75 22.00 0.00 30.75 30.75 .00
REVENUE DIVISION TOTALS--> COLLECTED: 30.75 OVER/SHORT: .00
BLDG PMT PLUMBING ELECTRIC ME�HANIC FIRE SMIP/TOT GR�DING PLAN-CHECK
30.75
..i
�E if jF if iF jf iE iF iF it �f 3F itlf iF iF iF ii iElf 3E ff -lE �E iE �E iE iE iE 1E iF iF �E aE jE �1E �1E �E jE �1E iE �E fE jE iE if iE �E �E jE iE iE jf dE iE iE �E �E iE �E �E �1E if ik iE it iF-1(� iF 1F if iE'N� it iF �lf �E �E �E
I N D I V I D U A L . F� E E H R E A K D O W N
'FYPE QTY D E S C R I P T I O N UN2T COST TOTAL CUST
PLU 1 DISHWASHER "�:•�t 8.75 8.75
�ENL� OF FEES
;: ���
� 6 ,� oa
D�►�
(515t-16.WP) WhNe-B�ilAmp 8 Sefery: OreerFle; Cenery-App5cent; Pink-Rewnua; Ooken�aLl�eaeaor _
� _ � �
fl8-25-1937/IE:06 AK/f30.75
kCFTq:�l-0611"c53
RERI`9I T : 084353
CONSTHUCTION AND PLANNMG POC SPA
APPROVA4S Permit # Date Inspector AppROVALS Permit # Date Inspector
1, Temporary Electrical Service or Pole 52. Pool & Equipmeni Lucation
2. Soi! Pipe�Undrgrnd. � 53. Steel Reinforcement
3. Electrical Conduit Utility•Undrgrnd. 54. Forms
4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding
5. Stee! Reinforcement 56. Rough Piumbing & Pressure Test
6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE
7. Footings 58. Electriral Conduit-Undrgmd.
8. Foundation 59. Gas Pipe, � Undrgrnd., Test �
9. Water Pipe-Undrgmd, � 60, Backwash Lines, P-Trap, � Undre�rnd.
10. Structurai Floor System 61. APPROVAL TO DECK
i t. Property Sewer Line & 4ouse 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 Svstem�Finai -
1&. Rough Electric Wiring 67. Fencing & Access Approval �
17. Rough Wiring SiSn 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 #�
2L Ducts, in $tructuse . 70. Undergrnund Hydro
22. DuMs, Ventilating 71. Product Piping Cl Gas � Oil
23. Gds Pipe�Rough & Tesc 72. Underground Flush ,
24. Rbof fram�ng 73. Under9md. Stora9e Tank C7 Gas ❑ Oil
25. Roof Sheazhing - 74. Overhead Hydro �
26. T-Bar Ceiling IStructurat) & Monocoat 75. Dry Chemical �
27. Frameand Flashing. 7g, Dry Standpipe ,
28. Lathing & Siding ' 77. FIXED SYSTEM FINAL
29. Insulation � 78. FiRE PREV. FINAL
30. Drywall Neiling HEALTH DEPT. REQUIREMEN7
31. Plaster Bro�vn Coat . � 79. FINAL INSPECTION
32. Electrical Power Meter�Final 80. FOOD CERTIFiCATE ISSUED
33. Final Electric , Notes:
34. Final Heax�ng & Air Conditioning � q�8��, �(,�6 �%CGL'}SS _
35. Final Gas PiPe-Test ��j ND �CGGs`�
36. Hood or Canopy
� 37. Final Factory Firepiace ��
38. Final Plumbing J.',�b,�q ��
� 39. Water Service�Final � � �
40. Gas Service-Final , a
41. Solar pomesticFinal '�
42. Backflow Preventer �
43. Backfiow Irriqation
44, Landscape Irriqation System
45. Sound Attenuation
46. Handicap Regulations -
47. FINAL S7RUCTURE & BUILDING
48. FINAL PLANNING ,
49. Electric Release ro Edison �
50. Gas Release to Southern California Gas Co
51. CERTIFICATE OF OCCUPANCY
No. Date
� a�� f�
LOSTA MESA BUILDING-SAFETY DEPARTMENT
P.O.BO%91] C06TA M66A�CALIFORNIA
For Applicanf fo Fill ln Complefely
TYPE OR PRINT �
BUILDIN6 /` o� (�
ADDRESS (/ � Ch /J S� �
COSTA MESA, CALIFORNIA
OWNER 5� - , Sq -' n 3-- .e
MAIL___ �%/.` �n� _ l` i'� cTn� �ST
FEE RECEIVED
,➢RN 2 7 1965
fINANCE DEPT.
CITY OF COSTA MESA
�PPLICATION FOR PERMIi
BUILDING
For Oifica Use On1y
flCG[IPTNO. pGq�.{IT�NO�
LVL! I
O T[PCC VH� ��Ej53 EO
2 � (�
3 c��/ 2 t� �n �,� _ �
F.FI'�r I �LANe .� I BUILO� O
CONTRAGTOR � J O - p • V ` , ^ � �
AODRE88 �• nn � �� D6iCRIPT1oN O%
CITY � N � D V- A. P. NO. �' � I!�I �� I
h ? NOTE: NO EAV E OYERHAN6 SHALL BE LE35 THAN
LIC.TNO. � I� S NO. S.J/ -�J 90" TO SIDE @ REAR P. L.
EAVES
SIZE rvo.oReLoae. O ALLOWED (U.B.C.REQUIREMENT)
OF LOT D O NOW oN tAT
YARDBAPPROVED YARDSAPPROVEO
USEOF MAINBUILDIN6 ACCESSORYBUILDIIJG
EXISTING BLDO.
( FROM C/l STREET
6ETGACK LIH6 FROM q FRONT FT. FT.
cEHTex OF eta5ef . J—� REAR YARD � O�
�-7 Q //
SIDE YARD I LEFT � I RIGHT —� R. SIOE / PT. / FT:
DESCRIPTION OF WORK L.81DE Fr.7 Fr.
REAR � �, tT.
NEW � ALT6RATION _ ADDITION .
DISTANCE BET. BET. MAIN Q
REPAIR MOVIN6 DEMOLI8H MAIN BLD68. ACCE59.BLD6S.
BUILDINO ryQ,pp �} p� VAR.# DATE
SIZE ROOMS 6 6TORIE9 f/� C.U.P.# APPROVED
EXTERIOR WA4L ROOF B PROY DATE �� �' 1
COVERING 9 UC c0 WYERIN6 � 0 0 c� � � J
USE OF BUILDING AND WORK TO B6 PERPORMHD
� Nn a- � m 4 Ci�s �n
�.
�y T r e s =X <ti� '7 � D �
so. Fr.
1 XEREBY ACKNOWLeD66 THAT 1 X�Ve qEAD TH19 �PPLICATION THE AMOUNT 9H0 N UNDER VFLIIATION 19 FOH THfi F
AND 6TATE TH/�T TX8 A60V8 I8 CORqHCT AND AOREH TO COM. PURP09E Op H6TABLI6H�NG • PEHMIT FEE ONLY. �
PLY WITX ALL CITY OFO�NANC86 AND BTAiB LAWB RiOULATIN� YALUATION �7 q
aulLo�NaCONBTxucTloN. �J PERMITFEE $ / �� a
SIGNATUREOF �j Y' , / ���� �
PERMITTE ! �%G, m
S �� �/ LAN HECI �' O
AUTHORIZfiO A6HNT / �-j__
C
TOTALFEE J