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HomeMy WebLinkAbout162 BROOKLINE LN - Building Permits ADDRESS OF SUKDNO: 162 BROOKLINE LN UNT: CITY OF COSTA MESA - BUILDING PERMIT OWNERS NAME IF MOWN: CARTER, LEROY T PERM NO; 8 072655 ADDRESS 6147 ARROWROOT LN RANCHO PALOS VERDES, 90274 PERMIT NO: B 072655 PLAN CHECK NO: N GOVT; N STJPP : N APPL.MAIUNO ADDRESS CONSTRUCTION TYPE: VN PERMIT TYPE: SIR PURPOSE: OTH ARCHITECT OR ENGINEER: UC NO.: JOB DESCRIPTION : T/OFF, SHEATH & REROOF W/COMP SHINGLES SQ FT: 2. , 924 ARCH.OR ENG.'S ADDRESS: UMT: CLAIM VALUE: 2, 924 . 00 CALL-VALUE: 2, 924 . 00 GROUP OCC: R-3 / cowincTowsNAME: STOUT ROOFING INC ( 310) 923-6775 CONTRACTORS MAUNO P 0 BOX 4309 COMMENTS: SMOKE DETECTORS REQUIRED PER 91 UBC ADDRESS DOWNEY CA ucmo.: 402536 *******************************sERE+EDE*RE*>E*RE*********aE**acacaESEaE*RE**>ERE***R ***>E*RE>FDE>E*>E 90241 WIT: 7. O N I N G REQUIR EMENTS LICENSED CONTRACTORS DECLARATION:I hereby affirm under penalty dprovisions jury that I am licensed under of Chapter 9 S ETB AC K S (commencing with Section 7000)of Division 3 of the Business and Profession end my license is in full force effect. CITYLIO.No.: 59 77 ma-Ass: C 39 mm 4 2516 EX 10/ 5 MAIN BUILDING ACCESSORY BUILDING /Q / RNT: FT • IN REAR: FT IN FRNT: FT IN REAR: FT IN la ,, -/ 9_1 co,..../ Gni / LEFT; FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN OWNER BUIL ER D CLARATION:I hereby affirm under penaly of perjury that I am exempt Iron the Contractors Livens w 1«the following reason(Section 7031.5 Dueiness and Professions Code:Aro city or moony which requires a permit to construct, er,improve. PARKING REQ: P ROV: PARCEL: 41916412 Z N E: REF NO demolish,or repair any Moisture,prior to Is issuance.also requires the applicant for such permit to file a signed statement that he or she PLANNING NOTES> is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commenting with Section 7000)of Division 3 of the Business and Professions Code]or that he or she is exempt therefrom end the basis for the alleged exemption.M y violation of Semon > )W1.5 by any appticenliweperme wbledelhe apdkanl toeavil penally of not more than five hundred dollen 1$5001). *****************************IE***)E***************K***********************WS**)4-3b 0 L m owner d the property or my employees with wages as their edit compensation,will do ms worlr,end the structure b red intended 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 or offered for sale(Section 7044.Business and Professions Cont:The Contractors License Law does not appy to an owner of property who buids or knpoves(hereon,and who does such work himself or herself or through his or her own emMoYees,presided that such ., improvements are rotintended«offeredfor aele.ff.however,the building«knpovemenl is sold within one year ofmmplerion,theIllZONING APPROVED BY DATE: nenbuilder will have the burden of proving he or she did not build«improve for the purpose of sale). s owner of the property,am exclusivey contrading with licensed contractors to mnstrua the project(Red'on 7044.Business errdBU11.01NG APPROVfiD AY DATE; fessions Code:The Contractors Lcense Law does not appy to an owner of popery who builds or improves thereon end who mracn 1«eudh projWs wRh a mmrect«(a)Ikensed puthi to the Contradare Liceroe Law). / is /am exempt under Section: a.aP.c..formle reason: APPLICATION ISSUED BY; DATE- /�l/J TVP/� iLl�1!/F/ .. -- ********************************* ** ****************K**********lE*KiE* * * * Dat o....: "° LEGALIZATION:N FEE U M M A R Y STRUCTURAL SEG E.NT:Y I do hereby certify that I am aware of and understand the requirements of Ca t:mre Health and Safety Code Sets 25505,?gasp,end 25534,andthat l or any Murebuiking ocupan,vill/will not(dmle one)need to campy with said state codes and the requirements l« BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING a permit lor construction or modification from the Ar uely anagemenl District.Residential condnidion appimi«n are exempt from these PERMIT 54 . 00 . 50 provisions. Date: Applicant: S M I P/NON-RES PLAN WORKER'S COMPENSATION DECLARATION:I hereby affirm under penally of perjury one of the following declarations: ISSUE FEE O have and will meintanecetaeof consent toself insurefor w«kers'mmpenmion,asprovkledl«bySection 3700ofthe Labor iilBUILDING DIV-> PERMIT ISSUE.. PLAN-CHECK TOTAL PAID DUE Cede,mrthe ped«ntsncewthe work mN rwahthis pennnnissued. TOTALS----> 54 . 50 0 . 00 0 , 00 54 . 50 54 . 50 , 00 I have and suit maintain compensationworkers'compensationn lipn insurance, required by Section 3700 of the LaborCode,for the performance of the R work for which this permit is issued.My workers'mm inion insurance cenir and policy number are: Carrier: STATE EXPIRES REVENUE DIVISION TOTALS--> COLLECTED : 54 . 50 OVER/SHORT: 00 Policy Number: 04494U0004bl / 10/19/95 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMTP/TOT GRADING PLAN-CHECK (This section need nor be completed it thepenni is fa one hundred dollars MOO • less) 54 . 00 . 50 o I certify that in the performance of the work for which this permit is iss Ind em•• any person in/manner m -to beecomesatlyet to tan workers' kersi compensation lawsLaof e.iiWnia,l that I,. . beco to the *****************************************K**********************************K** \shall/ ., "rj �/. T. N D I L I D U A Lr F E F. B R F, A K DOWN Date: (B 4S- Applicant/X.- pdcent:l� Warning:Fel re um workers'compensation coverage Is unlawful,and shall subject an employer to criminal •nsidn and TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST civil fines up to one hundred thousand dollars($104000).In addition to the cost of compensation,damages as ••sided for In Section 3706 ofteLaborCode,Int«ulendsttoey'afees. SFR 2924 REROOF BY VALUE RESIDENTIAL NO7ONE 1. . 00 2. , 92.4 . 00 CONSTRUCTION LENDING AGENCY: I hereby affirm under penally of perjury that there is a construction lending agency for the END OF FEES performance of the work for which(his fermi is issued(Section 3097,civ.C). LENDER'S NAME: LENDER'S ADDRESS: I certify that I have reed this application and state that the above information is correct.I agree to campy with all by and county ordinances and state laws relating to building construction and hereby authorize representatives of this city to enter upon the above-mentioned property for mspedion purposes. LENE BURFORD/ Prfame / ��J�// Pf ams .� •/ - •..e:� 01 001$3.34-0U1S 435 1-i OT -_ /` Signature aiewrrer/Agent/Appliteel ontrador DATE: Oa;05/9 TIPE: 10:30 (5151.45.WP) White-Building A Safety:Green-Fle:Canary-Appkcant;Pink-Revenue:Goldenrod-Assessor CONSTRUCTION AND PLANN, JOL & SPA APPROVALS Permit # Dateillii :or APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or'P6 e 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, 0 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 Electrica6Conduit • 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 Conditi6"nidg FIRE DEPT. REQUIf2'EMENT 20. Rough Factory Fireplace • . • ' APPROVALS Permit # 21. Ducts, in Structure - •• • 70. Underground Hydro 22. Ducts, Veniil ting 71. Product-Piping D Gas 0011 23. Gas Pipe-Rough & Test 72. Underground Flush ' 24. Roof Framing - • -' • - 73. Undergrnd.Storage Tank ❑Gas 0 Oil 25. Roof Sheathing 6-41-14-4a-a) 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 ' . 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 - 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 44. Landscape Irrigation System ci - ' 45. Sound Attenuation - 46. Handicap Regulations - - 47. FINAL STRUCTURE & BUILDING /`0-.. '6(„�(, 48. FINAL PLANNING [ I - 49. •Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No Date Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. 9129 - 9/2603 Cn: I CITY OF COSTA ME nA CONSTRUCTION PERMIT PERMIT NO. TRACT NO. LOT NO. UNIT NO. Project Address 1 �vCQO E/JU, P O'1( 0 o 1 LI Apf'}iCant's Mailing Address TYPE OF CONSTRUCTION Li NEW ADD )(ALTERATION 0 REPAIR i ❑ CONVERSION ❑ DEMOLISH ❑ OTHER A.P. Zone Owner's Nam/G/ iyf7� .�-� Phoned-1262 DE �ON OF WORK E OF BLDG. Address /6-2 .Bi2ooki-we e • GIJ G S Main Building: Accessory Building: Z E Arch/Eng. License No. TYPE OF ERM)T GRADING 0 FOUNDATION U STRUCTURAL T Front 0 Address IDTENANT CIELECTRICAL *PLUMBING EllMECHANICAL B Rear N ^/� //�� I _ Contractor's Name l'A`l.YAtAt k Phone m•fr ti-< Ne ( I_ ❑ OTHER C Right N C 1 PROJECT DESCRIPTION SO. FT. OCCUPANCY Address(mailing) 1'��� ebh aid C.tY• `�Q 11 K' Left C' s15�1 CON ST RUCTION TYPE VALUATION$ S R City License No. 41 T ZONE GRADING CU.YDS. ACRES LICENSED CONTRACTOR DECLARATION Ping. Ref.# Parking Req./Provided E Q I hereby affirm 7 that) I am licensedion under provisionsBusnof charter i ns Code, n9 Remarks: Planning Notes: M with section 7000) of Division 3 of the Business and Professions Cotle, and T license Is In f II force antl'etfect. $ Ucens 55 IC Date Signature �F�S ]4 PLUMBING FEES • WOR RS'COMPENSATION DECLARATION ��— Bar Sink Showers ELECTRICAL FEES I hereby affirm that I have a certificate of consent to self-insure or a certificate - of Workers' Compensation Insurance, or a certified copy thereof (Section Backflow Preventer Service Sink - ❑ 15'50 KW 3800, Lab. C.) Automatic Washer Transformer Policy No. company Backflow Irrigation Sewer Cap Construction Pole Sub. 0 50+KW 8 Certified copy is hereby furnished. — Certified copy is filed with thehecity Building Division. Bathtubs Sewer Connection Cooking Unit • Meter Dup f0 100 amps Date Applicant EXEMPTION FROM WORKERS'COMPENSATION DECLARATION Clarifiers Solar Collectors Dishwasher Meter Dover 100 amps (This section need not be completed if the permit IS for one hundred ($100)or / less). Dishwasher , Solar Piping g Dryers ❑Gas ❑Electric Sub Panel certify certify that in the performance of the work for we • is permit is Is etl I Motors❑Ql HP ❑1 -B • shall not employ any person in any manner i •e subie /o the Drinking Fountains Solar Tank Fan Workers'�o��jjii��ee���j$�N����y�vvs of California. •Data .,jCJLy�QLSignature _�_- � Floor Drains Swimming Pool w/Spa F.A.U. Inc.Solar 09-15 HP ❑16.15+ 'NOTICE: I,after making this declaration, you thou • •ecom. sub'ct to the Workers' Compensation provisions of the Labor Code, you must forthwith Floor Sinks Urinal comply with such provisions or this permit shall be deemed revoked. Fixtures Microwave CONSTRUCTION LENDING AGENCY Gas Service Outlets Water Closet I hereby affirm that there is a construction lending agency for the performance Device Boxes Pole Light ��J • of the work for which this permit is Issued (Section 3097 Civ. C.) Interceptors ed Water Heater Outlets Range • Lender's Name .1'r • Lender's Address ' Kitchen Sink Water Service Switches Sign OWNER BUILDER DECLARATION .. I hereby affirm that I am exempt from the Contractor's License Law for the Lavatories Auto-Wash Garbage Disposal 'Standing Sections • following reason (Section 7031.5 Business and Professional Code: Any city or _ _ county which requires a permit to construct,alter,improve,demolish or repair P-Trap Laundry Trays Generator ❑0.5 KW ❑5.15 KW Trash Com actor any structure, prior to Its issuance, also requires the applicant for such permit P to file a signed statement that he/she Is licensed pursuant to the provisions of Roof Drains the Contractor's 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 any applicant for a permit subjects the applicant to a civil .5 Eghalty of not more than five hundred dollars($500). LJ I, as owner of the property or my employees with wages as their sole Reinspection Fee I $15 Issue Fee $ 3 OD - compensation, will do the work, and the structure is not intended or offered Reinspection Fee $15 Issue Fee $ 3 ' for sale (Section 7044, Business and Professional Code: The Contractor's MECHANICAL FEES s License Law 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 own DEVELOPMENT SERVICES REQUIREMENTS: employees, provided that such improvements are not intended or offered for Boiler Hood or Type I 0 sale. If, however, the building or Improvement is sold within one year of com- Canopy Type II ❑ Zoning Approved By Date P the owner will have the burden of proving he/she did not build or Im- Duct-Under Ground Building Approved By Date eve for t strove the purpose to of sale). LI I, as owner of the property, am exclusively contracting with licensed con- Duct-Structural Refrigeration System . Application Issued By Dat • tractors to construct the project (Section 7044,Business and Professions Code: The Contractor's License Law does not apply to an owner of property who Duct-Ventilating 00.100,000 BTU 0100,000 BTU SUMMARY OF FEES builds or improves thereon, and who contracts for such projects with a con- ' tractors) license pursuant to the who License Law). I am aware thatBUILDING PERMIT $ SMIP $ proof of their Worker's Compensation insurance should be provided to me. Exhaust System 0 Multiple 0 System Repair/Alteration PLAN CHECK $ PERMIT ❑ I am exempt under Section B.& P.C.for this reason Firepl/Fact.Blt. ICBO# Fire Dampers PLUMBING $ roe; ISSUANCE $ Dale Owner Heating System& Ducting Registers I _ I PLAN CHECK 25% $ ENERGY P.C. $ I hereby certify that I have read this application and state that the above ❑O-100,000 BTU ❑100,000BTL GRADING $ Information Is correct. I agree to comply with all city and county ordinances ELECTRICAL $ and state laws relatin• • building construction,and hereby authorize repro- MICROFILM $ sentatives of 'this liter ,on the above-mentionederty for • PLAN CHECK 50% $ �jy inspection pu :AY �j Reinspection Fee $15 Issue Fee $ 3 PLAN CHECK 25% $ CMF 0865.46,rev. 10/84 White - Building; Canary -Applicant; Pink •Accounting; Goldenrod - Assessor CONSTRUCTION AND PLANNING POOL& SPA APPROVALS Permit# Date Inspector APPROVALS Permit# Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location I 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3?;Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5, Steel illeinforcement . , 56. Rough Plumbing & Pressure Test 6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE 7.`Footing; � 58. Electrical Conduit-Undrgrnd. 8'.Foundation 1 59. Gas Pipe, 0 Undrgrnd., Test 9. Water Pipe-Undrgrnd. -' r t 60. Backwash Lines, P-Trap, 0 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-Conduit66. 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 0 Gas E 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. Fame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREV. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter-Final 80. •i'EOOD CERTIFICATE ISSUED 33. Final Electric Notes: ri 34. Final Heating & Air Conditioning 35. Final Gas Pipe-Test 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing 3-4-a LAO - 39. Water Service-Final 40. Gas Service-Final 41. Solar Domestic-Final 42. Backflow Preventer ' 43. Backflow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48. Special Requirements Completed 49. Electric Release to Edison - 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date UWNCK SAN VISTA BUILDING COMPANY DATE 10-4-67 JOB ADDRESS 162 Brookline Lane BUILDING PERMIT NO. 27652 GENERAL CONTRACTOR Sante DESCRIPTION of WORK ResidenceW/Att.Gara&e AP No. LOT 96 TRACT 5160 FIRE ZONE . VALUE E 18,114.00 ___ • INSPECTIONS Si•nature Date GROUP TYPE ZONE C- _ SOIL h SUBCONTRACTOR PERMITS ISS ED GAS Date Number Si•nature WATER(( ,S'/&//-G7 �/4� 'Iumbin• ROUGH PfUMB I NG L14 //1,.(/-(/7 re2rn. � /O S-6 O7 PROP. SWR. LINE❑ HOUSE CON. l— S/p•!^L,, / SPRINKLING SYSTEM MISCELLANEOUS ROUGH HEATING AND AIR CONDITIONING /V}hYj /i i? -0> TEMPORARY SERVICE OR POLE UNDERGROUND 0 POWER 0 ROUGH WIRING / //7 Heatin• and Vent. TRENCHES ❑ FORMS ❑ STEEL RE INF. 0 C (t //Cl`ne�g�Jsn��,r�)MA FLOOR SYSTEM ( Will BOND BEAM MI STEEL REINFORCE • ,,, �/� SHEATHING Lf1I/I�i///L"S FRAME AND FLASHING 5iMciI LATHING — IN U OUT PLASTER, BROWN COAT `i,1 /l ©L: STRUCTURAL. FINAL . �ry��/ . /�p HEATING. VENT., REF RIG. AND A.C., FINAL AZIM '6' ,iy� , ' ,. ..W.,M� `I•VI' PLUMBING, FINAL AND GAS TEST a - A; �� ELECTRIC, FINAL / .L4 ffr BUILDING, FINAL /en .F.7S 2 /fjb2 PAID .. .n', • 1 COSTA MESA BUILDING-SAFETY DEPARTMENT CCI 4 67L1 ;OO 1?6" P.O. BOX 1200 COSTA MESA, CALIFORNIA 92828 For Applicant to Fill in Completely APPLICATION FOR PERMIT TYPE OR PRINT BUILDING BUILDING ` � /U�,'', For Office Use Only ADDRESS 41 i LL"' -y RECEIPT NO. 2'7 52 COSTA MESA, CALIFORNIA LJ ��{Fll-•JJ��VV11 J/� �j-, \y�� � REM IY DAT [[C�iL7V J M/r�/��B�Yf�'/ �/ OWNER OLY4. OCA-A. ! --wS.�/.Q / L euILDING7q ! (/��/'-6AODRMAIL ^ ADDRDN /1 FIRE TL CITY °CULL, ( r N Le ri ZONE TYPE GROUP r ARCHITECT �(//��//��� 7EL��)�� APPROVED ✓.1117° DATEr'LG^ n OR ENGINEER Ui i 1ri"2�F'/1�•N_. NOUS 21 flat B'' 41". , .l G �,/ ADDRESS gip-1-111,/ C -/-lacHfl -o-� �" �'�r ZONE ^ 4 NO.OF f USE OFNIWly—.e • CONTRACTOR QN•N-(-H /i \�.{Ir/mow_ /e LEGAL ( J I,' (.i6 --rmet�-.)[ &0 ADDRESS 9 Qy^.1 A/� D[sCRImOK A A.P.NO. i / , [30 -03 CITY (1 in..) (Ar/ NOTE: NO EAVE OVER NO SHALL BE LESS THAN STATE TEL BO•TO BIDE a REAR p.L LIC.NO. NO. EAVES SIZE U _ x Ic NOW..QLE1OSi.� ALLOWED (U.B.C.REQUIREMENT) OF LOT �•(� ON IDT YARDS APPROVED YARDS APPROVED USE OF MAIN BUILDING ACCESSORY BUILDING EXISTING BLDG. ^'--' (FROM C/L STREET) BETRACILLUULARISFRONT OFT. PT. CENTER OP STREW REAR YARD SIDE YARD LEFT RIGHT R.SIDS d FT. PT. DESCRIPTION OF WORK L SIDE 0 PT. Fr. NEW ALTERATION ADDITION REAR O PT. FT. DISTANCE BET. BET.MAIN It REPAIR MOVING DEMOLISH MAIN BLDOS. ACCESS.SLOGS. BUILDINGnn � NO.OF [/ VAR.* DATE SIZE . .0 X70 ROOMS r STORIES C.U.P.A APPROVED EXTERIOR W ROOF Pp /�� APF�/p/VED COVERING Afd.R.'j COVERING K•-d'T�"C. BY l`I • r . D, DATE ( —��`107 USE OF BUILDING AND ORK TO RE PERFORMED 0l"( / C, C Cicp &L/L14^. -, 9 71---- �.3/1° BQ.FT. yTa et I HEREBY ACKNO •'1 THAT., HAVE APPLICATION THE AMOUNTS UNDER VALUATION IS FOR THE - AND STATE THAT BOYS.15 CORRECT AND AGREE TO CON- PURPOSE OF i*TAGLISHING A PERMIT PEE ONLY. PLY WITH ALL CI 0 •INANCEU AND STATE LAWS REGULATING BUILDING CON• RIO • VALUATION // D SIGNATURE OF A -' $/QJ /// PERMIT FEE $ CO o W PERMITTE /(///y E PLAN CHECK $ ?� w AUTHORIZED •E / yhO . .. . _ TOTAL PEE $ /