HomeMy WebLinkAbout268 BUCKNELL RD - Building Permits(714) 754-5273 � Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
BUILDING PERMIT
,lob Address: 268 BUCKNELL RD
Suite:
Vicinity: ROOF
Parcel Number: 41913507
,4pp�icant: SCO7T ANDERSON
Address: 18479 SANTA CARLOTTA
FOUNTAIN VALLEY, CA
owner: SHARP, LUANA R
Address SHARp, LUANA R TR
COSTq MESA, CA
268 BUCKNELL RD
Contracror. SCOTT ANDERSON
Address: 18479 SANTA CARLOTTA
Arch :
Address:
FOUNTAIN VALLEY,CA
Zip: 92708
Phone:
Zoning:
Phone: 714-209-6006
Zip: 92708
Phone:
Zip: 9262G6137
Phone: 714-20&6006
License: 827255
Eng:
Address:
Status: ISSUED
Applied: 02/O7I2005
Issued: 02/01/2005
ISSUED BY: �
Phone:
Zip: License: License:
SCOPE OF PERMIT
INSTALL 2 NEW SKYLIGHTS BEN/EEN EXISTING RAFTERS LOCATED IN BATHROOM AND HALLWAY. ICBO #3933.
Plan Check: $Q.00
Permit: $54.00
SMIP Res: $0.50
SMIP Com: $0.00
Other. $0.00
Inspection: $0.00
Total: $54.50
SETBACKS
MAIN STRUCTURE Fron[ 0- 0
ACCESSORY Front 0- 0
PARKING Existina: p
NOTES:
Rear 0- 0
Rear 0- 0
Required: 0
FEE SUMMARY
PLANNING & ZONING
Lefl 0- 0
Left 0- 0
Proposed: 0
Calc Valuation:
Claim Valuation
Righl 0- 0
Righl 0- 0
Si,5oo.00
51,500.00
NO710E: The work authorizeq by this permit shall comply with all applicable handicap access requiremants under Califomia statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21•g2)
EXPIRATION: This permit shall automatically expire and become vold if work Is not commenced within 1B0 days, or If work is suspended or ebandoned
for a period ot 780 days.
INSPECTIONS: In order for the vrork euthorized under this permit to be considered legal, such work must comply with all appllcable codes, and all
requlred Inepectiona and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiratlon oi this permit.
FOR INSPECTIONS CALL: (714) 754-5626
xaaae �aroo�
WORKERS'COMPENSAnON DECLARATON:
I hereby eXirm under penalry ot perjury ane of the following declarations:
❑ I heve end will maimain e certifwte ot consenllo sell-Insure lor workers' compensetlon, es pmvided Por by section 3�00 of t�e Lebor Code, lor Ihe pertormance of t�e
work tor whith t�i5 pe�mit is issuetl.
❑ I have flnd will maintain workers' wmpensaUon insurance, es requiretl by section 3700 of Ihe Lebw Cotle, lor ihe peAortnance ot the vrork tor whkh this pertnit is issuetl.
My workers' wmpensatlon Insurence wrrier end pdky numbar ere:
Cerrier: Policy Number:
(Thls sectlon need nof be comp/etetl il Me permif /s velued et one hunOred tlW/ars ($100) or /essJ
�� I Cartity thet in the pertormance ol the work br which Ihis pertnit is issuetl, I s�ell not employ any person in eny manner so as to become sub�ect to the warkers'
ompensetlon laws ol Celifomla, end e ree thet II I should Eecome sub�act to Ihe warkers' compensetlon provislons of Sectlon 3700 ai the lebor Coee, I shall toR�wiih
comply with Ihese provi
PP��mS,.gnatuf--� re: -�_— �� ."Dete: . � I _ � �
WARNINCi'FAI URE TO SECURE7CORKERS' COMPENSATION COVEMOE IS UNL4WFUL AND SW1LL SUBJECT AN EM YER TO CRIM1llNAL PENALTIES AND CIVI� FlNE$ UP TOONE HUNDRED
TNOUSFNO WLLARE (5100.000�, IN ADDfiION TO THE COST OF OOMPENSATION, �NAAGES AS PROVIOED FOR IN SECfION 3]OB OF THE LABOR CODE, IMEREST, AND ATTOiiNE1"5 FEES.
CONTRACTORS DECLMATON:
(commencing with Sectlon 7000) of Dlvlsion 3 0l the Buslness�tl Professlans Code, and my license Is In fW
CONSTRUCTION LENDING AGENCY:
❑ I hereby eflirm Ihat there is a construction lentling eBency br ihe pedormence ot Ihe work lor which ihis permil is issuad. (Sec. 3097, Civil CoCe).
Lentlefs Neme: Lontlers Address:
Signature:
OWNER-BUILDER DECLARATIONS:
Date:
I hereby effirtn thet untler penelry af perjury Nei 1 em E%EMPT FROM THE CONTRACTORS LICENSE LAW for the tollowing reason (Sec. 7031.5, Business enC Professlons
Code: Any ciry ar counry which requires e parmit to consiruct, alter, improve, damolish, or repair any siructure, pnor �o its issuance, also raquires t�e epplicant for such pertnit
lo file e signed stetemem that he or sha is Ilcensed pursuant to the provisions at the Cantrectors License Law (Chapter 9(commencing with Sectlon 7000) ot Division 3 of t�e
Business end Professions Code) or ihat he or she is exempt iherefrom and Ihe basis tor the ellegetl e:emption. Any Wolatlon ot Secilon 7031.5 by any applicant tor e pertnit
subjects the epplicant to a civil penalry of not more Ihen five hundretl tlollars (5500)J:
❑ I, es owner of the property, or my employees wlth wages as their sole compensatlon, WILL DO THE WORK, and the strucwre is not intentletl or otlered for sale (Sec.
7044, Business antl Professions Code: Tha Contrectors Licensa Law does not apply to en owner ol property w�o builds or improves ihereon, and who does such work
himself or herself or �hrough his or her own employees, provided that such improvemenis ara not Intentletl or oNered lor sale. If, however, Ihe building or fmprovement is
sold within one year of completion, the owner-builder will have the 6urden of proving that he or she tli0 no� build or improve tor Durpose of sale.). '
❑ I, as owner ot the property, em EXCLUSIVELV CONTRAC7ING WI7H LICENSED CONTRAC70RS to construa the proJed (Sec. 7044, Business and Professians
Code: The coniractors License Lew tloes not epply to en owner ot propeny who bullds or Improvas Ihereon, and who comracts for such project with e contractor(s)
license pursuant to the Contractors License Laws.).
� I em exempt untler sac. Business antl Prolessions Cotle for tNs reason:
Signaturo: Daia:
Owner ID verifietl by tlrivefs license. ❑ Yes ❑ No Dnvels License No.
Vedlication ol Ownership by (type ol daumem, i.e. - property ten bill ar deetl):
DIVISION OF INDUSTRIAL SAFETY PERMR CERTIFICA710N:
Expires:
❑ I hereby cartity ihat no excavation frve (5) or more teet In depth into which e person b requiretl lo descend, will be metla In connectlon with work authorizetl by ihls
permit, and thet no Duiltling structure, scaHOltlinp, talsework, or Uemolitlon or tlismantling thereof, will be more then thirty�six (36) teet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Ttle B, Celitomia AtlminisUaOve Cotle).
❑ As owner-buildar, I will not employ enyone to tlo work which would requlre e permit trom the Divislon of Industrial Sefery, as noted ebove, unleu such person hes e
permit to do such work from �he division.
Signature: Dete:
Divlslon af Intlustnal Salery Pertnit Number.
CERTiFlCATE OF COMPLIANCE AND AUTHORPJITON OF EMRV: I certity under penalty of perjury that I have read this flpplication end state tha� �he Infortnatlon given is
CorreCt. I e9ree to wmpty with ell stete laws end Ury ortlinances relating to 6uilding consWclion, end authodze representetives ol t�e Ciry of Coste Mesa to enter upon the
ebove-desCnbed pmperty br insDection purpaaes. I egree not to acupy or allaw occupency of any building euthorized by this permit until finel inspection.
LODE t. INSVECTION7YPE Qdg URIDAL$
1616 Flxetl System Final Fire Preventlon
1286
200
201
202
203
204
Pool Spe Final
Final Re-Roof
Final Blak/Retaining Wall
Finel Fectory Fira Place
Finel Sign
Finel Demoli�ion
LO�E I INSPECTION TYPE
208 Finel Mechanical
208 Finel Plumbing
210 Finel Electncal
212 Final Fire Preventlon
220 Final Planninp Approval
222 Final Site
250 Final Building/Occupancy
�-
>.,2
It�EIS
Dlvitilc�N ��i' i;un.l �in�, s:u��"l'Y
Cliti ��c COSIn Mr;;A
I' i' i</ i)� 1�. 1) Q�
l� Dale
Th15 6e� at plan. ,u.n .:,�„�.ihi.alions MI IS1 be kepl nn Ihis �oi. .�� �JI ;nne5 and B i51111�►dd t.
R18k8 elty Chei air� -v .n:.�,nu �i�s ai snn�e nnl�n n+.rlc•i � yeniutiswM� Uau Ii K UMSip10�&i��y
and Salely. Gr: �� ��;�.� �.i•:.,�
jhg512Rqntxlulli�n.�,��+�..�:��ttiUF�+h.n!uunJHPLi f�OThene�dtopennno�tobean�lOY�
ol Ne violaliun ot nuy : uvisions r nny Gity oi Cosia Mesn Uidivancc nnNo� SIeU IBMI.
jh95g p2f15 and pennA cnaii expne Lv hmlialion and beC�ine nuli NM VOW A U1C 6U11� d
�mk's not wnunencetl mw mamw� �ad active pe� UBC §3031d) wilhin 180 days of �.
��� ���q�
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(714) 754-5273 • Fa�c (714) 754-4056 • vnvw.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
BUILDING PERMIT
JobAdd�ess: 26$ BUCKNELLRD
Suite:
Vicinity: RESIDENCE AND ATTACHED GARAGE
Parcel Number: 4 y y 13507
App�icant FERGUSON, LEW
Address: 4091 E LA PALMA
SUITE D
ANAHEIM, CA
Owner: SHARP, LUANA R
Address SHARP, LUANA R TR
COSTA MESA, CA
268 BUCKNELL RD
Contractor. MC CORMACK ROOFING
Address: 4091 E LA PALMA
SUITE D
ANAHEIM, CA
Zip: 92807
Arch :
Address:
Phone:
Zoning:
Phone: {714) 630-5543
Zip: 92807
Phone:
Zip: 9262fr6137
Phone: (714)630-5543
License: 643700
Eng:
Address:
ISSUED BY:
Stalus: ISSUED
Applied: 01/O6I2005
Issued: 01/06/2005
Phone:
Zip: License: License:
SCOPE OF PERMIT
REROOF RESIDENCE AND ATTACHED GARAGE: T/0 EXISTING WOOD SHAKE, FILL IN SPACED SHTG, 1 LAYER 30# FELT, APPLY'OWENS
CORNING 70-YEAR COMP SHINGLES' 29 SQUARES
Plan Check:
Permit:
SMIP Res:
SMIP Com:
Other:
Inspection:
Total
$0.00
�12525
$0.60
�0.00
$0.00
$0.00
$125.85
SETBACKS
MAINSTRUCTURE Front 0-0
ACCESSORY Front 0- 0
PARKING �xi_ stinq: 0
Rear 0- 0
Rear 0- 0
Re uired: 0
FEESUMMARY
PLANNING & ZONING
Left 0- 0
Left 0- 0
Proposed: 0
Caic Valuation:
Claim Valuation:
Right 0-0
Right 0- 0
36,000.00
Ss,a0o.0o
NOTICE: The work authorized by ihis permit shall comply with all applicable handicap eccess requirements under California statutes and related
regulations. (Ord. No. 92-29, § 1, 1241-g2)
� EXPIRATION: This permit shall automatically ezpire and become void tl work Is not commenced within 180 days, or It work is suspended or abandoned
i for a perlod of 1 BO days.
I INSPECTIONS: In order lor the work authonzed under thls permit to be considered legal, such work must comply with all applicable codas, end all
� required Inspectlons and final approvel must be obtained. Failure to ob�ain inspections end final approval will result in the expiratlon ot this perm0.
� FOR INSPECTIONS CALL; (714) 7545626
244&48IB/00)
WORKERS'COMPENSATONDECLARAnON:
I hereby eHirtn untler penalry ot perjury one ot the lollowing declarations:
❑ I h entl wlll maintein e cenificete at cronsent to selbinsure tor workers' compensation, es provided for by section 3700 ot Ihe Lebor Code, for the peAortnence ol the
ork tor wMU this pertnit is �ssue0.
I have tl will maintaln workers' compensatl Insurence, es reQNretl by sectlon 3700 of Ne Labor Code, lor the performanca oi the work tor which this permit is iswed.
My w ers' compensatlon Insurenc carri nd policy number e�e: ��
Cerrier, Cln75N✓La.�Ce � L�'a �/'�C PoIlcyNumber. �e�%��O�ID�C7DO�
(Thls secNar need nof be complB�ed 1! e Oermil s velued et one hundred tlallers ($f00) or less.)
❑ I cenity that in ihe peAorma�ce ot the work lor which this permit is issued, I shall not employ eny person In any menner so es to becwne subJect to the workers'
compensatlon laws of Ca orn�a, enC agr e ihat II I should become sublect to t�e workers' compensetlon provisions ol Section 3700 of t�e Lebor Catle, I shall t6Mwith
comply wiN these O�o ' ohs. ,/�{1� � �
AppliceNSignaNr �����ffu-(�.-�� Date: GI/O�v/O S
WARNINO: FAILURE TO SE� pE WO�ERS' OOMPENSA ON C vEMGE IS UNLAWFl1L AND SHALL SUBJEGT AN EMPLOVER TO CRIMINAL PENALTIES AND CML FlNE$ UP TOONE HUNDRED
TMOUSAND DOILARE (5100,000), IN MDITION TO THE COS .LdMPENS/TION, OAMAGES AS PROVIDEO FOR IN SECTION 3708OF THE IABOR COOE, IMENEST, AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hareby ottlrm �ho� I am
lorce end eflecl. Lic. a_
Contrectors Signemre:
(commencing wlih Sectian 7000) of Dlvision 3 of the Business and Prolessions Code, entl my license 19In tull
Class s
���— Date: O/� U Lo O S
CONSTRUCTION LENDING AGENCV:
❑ 1 hereDy ettirm that there is e construction lending agenc,y tor I�e peAortnance ol Ihe work for which t�ls permi� is Issued. (Sec. 3097, Civil Code).
Landers Nema:
Slgnawre: _
OWNER-BUILDER DECLARATIDNS:
Lentlels Address:
Date:
I hareby eHirtn that unCer Denalry of perjury Ihet I em EXEMPT FROM THE CONTRACTORS LICENSE LAW for the tollowing reasan (Sec. 7031.5, Business and Protesslons
Code: Any ciry or wunry whic� r9quires e pertnit to canstruct, elter, improve, demolish, or repair any aWcture, prior to its issuance, elso requires ihe eppliwnt for suc� pertnit
b tile e signetl stetement ihal he ar she La Ilcensed pursuant ro t�e O�oNslons ot the Contractors License Law (Chepier 9(commencing with Sacllon 70W) of Division 3 of the
Business end Professions Cotle) a� �hat he or she is exempt therefrom end the basis for the alleged ezemption. Any violation of Sectlon 7031.5 by any epplicant for e permit
subJecis the epplicant to a civil pe�elty oi not more than frve hundred dWlars (5500).):
� I, es owner of the property, or my employaes vrith wages as ihelr sde compensation, WILL DO 7ME WORK, entl the sirucNra is not intendetl or oHeretl tor sala (Sec.
7044, Business and Proles5�ons Code: The Contractors License Lew does noI apply to en owner of property who builds or improves ihereon, end who dces such work
�imself or herself or Ihrougn his or her ov.•n employees, provided that such impmvements are not IntendeC or oflered for sale. tl, however, the builtling or improvemeni is
sold within one year of compleuon, t�e owner-builder will have the hurtlen of proving that he or sha did noI build or improve for purpose of saleJ. �
❑ I, as awner ot the propeny, am E%CLUSIVELV CONTRACTING WITH LICENSED CONTRACTORS to consWct Ihe pmject (Sec. 7044, Business end Prolessions
Code: The conirectors License Lew tloes not appy to an owner ot properry who builds or improves Ihereon, end who comrac�s tor such pro�ea with e contracroq5)
license pursuant to ihe Con�rectors License Laws.).
❑ I am exempt untler sec. Business and Professions Cotle for ihis reesan:
SignaWre: Date:
Owner ID venlied by drivers licensa. ❑ Yes ❑ No Driver's License No. Expires:
Vedfication of Ownership by (type of tlaumeni, i.e. - pmperry tax bill or deetl):
DIVISION OF INOUSTRIAI SAFEn' PERMR GERTIFICATION:
❑ I hereby cenity that no e:ca�etion five (5) or more feet in depih Into which e person Is required to descend, wlll be made In connection wlih work authorizetl by this
permil, end Ihat no building struCture, scaHolding, falsework, or tlemolitlon or dismantiing thareoi, will be more than thirty-six (38) leet high. (Chap. 32, Grp 2, Art 2, Sec,
341, Tltle B, Califomla Adminlsiretive Code).
❑ As owner-bullder, I will not emD�oy enyone to do work which woultl roQuire e permit from the Divislon of Intlustrial Sefety, es noted ebove, unless such person hes e
parmlt to tlo such wark from Ihe divislon.
Signature: Date:
DlWsian af Industnal Safety Permii Numher.
CERTFICATE OF COMPLIANCE ANO AUTHORIZA710N OF ENTAY: I cenify unAer penalty of perjury thet I have reed thls epplice�ion end stele ihat the infortnation given is
correct I egrea to comply wiih all sta�e laws end ciry ordinances releting to building consiruction, enC eNhodze representatives of ihe City of Cos�e Mesa to enter upon Ihe
ebove-descnbed property for inspeclion puryoses. I agree not to occupy or ellow occupency of eny building authorized by ihis permit until linel inspection.
CQOE 1. INSPECIIONTYPE
1616 Fixed System Final Fire Preventlon
1266 Pool Spa Finel
200 Finel Re-Rool
201 FIneI8locWRetalnlnp W9�1
202 Final Fectory Fire Plece
203 Finel Sign
204 Final Demolition
Pdg 1t�L5
�/�
� �/�� �0 S �
� Data
CODE 1 INSPECTION TYPE
206 Finel Mechanical
208 Finel Piumbinq
270 Finel Electdcal
212 Finel Fire Prevention
220 Finel Planning Appro�el
222 Finel Site
250 Finel Building/Occupency
Pdff ItS�El9
.
.�
• � '' •�-�- ��J2
COSTA. MESA BUILDING DEPARTMENT
P. O. BOX 31'/
COSTA MESA. CALIFORNIA
FOR APPLICANT TO FILL IN
Aooae�ss 2fi8 BuC�11811 Rd.
COSTA MESA. CALIFORNIA
OWNER
MAIL
ADDRE55
c�T� Neti ort Beach, Ca7-• T�o: hSI 6-
ARCHITECT SHIDB LIC.
OR ENGINEER NO.
ADDRE55 H81�1E
LEGI�L Lpi [�1
oescnivrioN NO. ��'
A.P. NO.
S'zE 62 x 100.l�S
OF LOT
USE OF
EXISTING OLOG.
SETBTCN LINE FROM
CENTER OF STREET �I�
RIGHT
. � ����� �
. • .. . .. ..r
APPLICATION KOR PERMIT
BUILDING
FOR•OFFICE USE ONLY
COSTA MESA. CALIFORNIA
FIRE
LIC. 1/.11 -- - '
NO.
TEL. APPROVED
NO. SBIR9 ' BY
----- 2029
NO.OF BlDGS. 0
NOW ON LOT
REAR YARD 2`J �
6
L'cFT
DESCRIPTION OF WORK
NEW p ALTERATION I AD�ITION
REPAIft ' MOVING DEMOLISH
� 5 ZIE DING � m� �O ROOMS V STORIE
!1
E%TERIOR WALL' . ROOF �
1
DATE
CORRECTIONS
ST/�TE�THFT THEVFBOVE IS CORRER �ND�RGFEE TO COMPLV WITN 1LL purpose of establishing a permit fee only.
CITY ORDINANCE9 O STATE L�W$ NEGULATING BUILDING CONSTPUC-
T�O�. VALUATION nn
SIGNATURE OF PERMiT FEE s.35�W
PERMITTEE 17 C/1
15,6��0o PLAN CHECH g ^'
s
AIITHORIZF A[:FNT TOTAL FEE 5 52.50 �r
OWNER ggpgp, JAMES
106 ADDRESS 2G$ g�ycknell f
GENERAL CONTRACTOR �r (
AP No. 1 1- -07 LOT 52
INSPECTIONS
soi�
GFS
W ATER
ROUGH PLUMBING
PROP. $WR. LINE � MOUSE CON. �
SPRINKLING SVSTEM
MISCEILANE0U5
ROUGH HEATING ANO AIR CONDITIONING
TEMPORARV SERVICE OR POLE
UN�ERGROUND � POWER �
ROUGH WIRING
TRENCHES FORMS � STEEL REINF.
FLOOR SYSTEM
BONO BEAM ❑ STEEL REINFORCE �
SHEATHING
FRAME AN� FLASHING
LATHING - IN � OUT �I
PLASTEti, BROWN COAT
STRUCTURAL, FINAL
HEATING. VENT._ REFRIG. ANO A.L. FINAL
DATE 6_�_69
BUILDING PERMIT N0.
SUBCONTRACTOR
F
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COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626
APPLICATION FOR BUILDING PERMIT
For Applicant to Fill in Completely
RECEI ED BV DATE ECEIVED D/AT IS VED
ADIDRESS �lJa JUCi[/�t�� L/� �I w� �
OWNER 7 m � .I% A.P.NO.��/ /�z �O7 MTN .
MAIL �/\7 j3 u cK Nf �-< ADDRE S Z(o8 BuG,('.t/ELL
ADDRESS (9 G
CITV GD �Ip � NO�. TRACT��Z� LOTSL BLOCK
CONSfRUCTION '�' � W ADD A P
LEN�ER
BRANCH /� {
OWNER T�iMFJ S/Y/�I�/- �/ �
ADDRE55 /� VALUE .�
W
ARCHITECT TEI. .SE d
OR ENGINEEF N
FIRE
ADDPESS ZONE � TVPE GROUP T
APPROVED �J /
CONTFACTOR �/�q BV (/' ATE� s,O
ADDRESS �OO �'/yj [7' (/!
TEL. � ZO((y�E NO.OF USE OF NEW� �p•M�
CITV �S� � / NO.S ZS2Ei •� —� PLANS Z BUILDING
STATE � /O�O CITV ' �'ARDSAPPROVE� YARDSAPPROVED
LIC. NO. LIC. NO. MAIN BUILDING ACCESSORV BVIIDING
SIZE NO.OF BLDGS. (FROM ^C/L ST[q EET) E�fT"
OF LOT 6� J( �O NOWONLOT 0�/ = ROfYT'T�R�"`FT.r J FT.
USE OF
EXI5TING BLOG. � G 5 �� FT. FT.
SIZE OF NO.OF I _
NEW BLDG. IcI �t I ROOMS � STOFIES l L. SIDE � FT. FT.
COVERINGALL f�G`U COVERING S. /`�S REAR � FT.f�/
FT.
USE OF UILDING AND WORK TO BE PEFFORMED DISTANCE BEf. BEf. MAIN &
�� a0A MAIN BLDGS. ACCE�. BLDGS.
VAR. #` OATE
D I' M 3 �S . c.u.P.� APPROVED
APPROVED u� J ^ ZT"b �
I hereby acknowletlge that I have read this application antl state
that the above intormation is correct antl OB�ee to comply with
all laws regulatln8 building construction, antl I shali not employ
eny Derson in violetion of the workman's compensaiion lews of
xhe State of Californle.
I hereby certity that I am properly licansetl as e contrector untler SQ. FT.
the State of Calitornia Business and Protessions Cotla, Divisicn 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR
Chepter 9, antl thet such licenses are in full force antl etfect, or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLV:
am ezempt from tha provisions ot the State of Calitornia Business
and Professions Cotle, Division 3, Chapter 9. VALUATION ��}' �
n PEIiMIT FEE $ O�
SIBna[ure of �/ _ � n / // /// ,�,,/] /^/�%
Permittee � •�_ _ _ i��%. . �W �i/L�ati�•�'1 5�� �/ I/_ • � PLAN CHECK $ �// � ✓ ✓
g T!(J - S' �
AuNorized A ent / TOTAL FEE $