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HomeMy WebLinkAbout3082 CEYLON RD - Building PermitsCITY OF COSTA MESA - � o�` MFS'q BUILDING DIVISION i�� 77 FAIR DRIVE. COSTA MESA. CA 92626 •(714) 754-5273 • Fax (714) 754-0856 • Hrvwi.ci.costa-mesa.ca.us : ° � FOR INSPECTIONS CALL: Q14) 754-5626 �`""'m� PERMIT NUMBER: BC09-00256 PERMIT TYPE: 6 COMBO Sub Type: POOLRRIP �os aooREss: 3082 CEYLON RD CM APN: 139i6509 Zoning:Rt, , Vicinity: POOLANpSPA Const Type: SQ. FT: 233 STATUS: ISSUED DATE ISSUED: 07/0912009 ISSUED BY: BJK Suite/Unit: Primary Occ: R3 Valuation: 525,000.00 SCOPE OF WORK: 233 SF IN-GRUND GUNITE POOL AND SPA AT THE REAR OF AN EXISTING SFD. ELEC: OWNER: BOAG, NIGEL Address: 3082 CEYLON RD Unit: Phone: Ciry/Sfate2ip: COSTA MESA, CA APPLICANT: ELLISON, PAUL Phone: 949-683-g661 Address: City/State/zZip: CON7RAC7oR: CALIFORNIA POOLS AND SPA License No. 185102 Phone: 714-575-9286 Address: 970 N TUSTIN AVUnit: Cell: CitylState: ANAHEIM, CA ARCHITECT: ENGINEER: AARON COWEN License No. License No.C58878 COMBINATION PERMIT FEE SUMMARY Building Plan Check: $254.31 Building Fees: $39125 Electrical Fees: $73.00 Mechanical Fees: $41.50 Plumbing Fees: $114.50 SMIP Residential: $2.50 SMIP Commercial: $0.00 Bidg Std Admin Fund $1.00 TOTAL FEES: $878.06 "Refer to (ee roccip�s for all fees paid (or project Unit: : SUITE 200 ZipCode 92807 PHONE: PHONE:774-630-6100 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: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permil 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 fnal approval will result in Ihe expiration of this permit. UE/. INSPECiIONTYPE DATE IN1111R1 COOE/ MSPECiIONTYPE �ATE IN1111AL5 1818 Fixed System Final Fire Prevemion 206 Final MeUanical Q 7266 Pool Spa Final �� 208 Final Plumbing 200 Final Re-Roo/ 210 Final Electnwl lI '« 201 Fina161ocWRetaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition � 272 Final Fire Prevention 220 Final Planning Approval 222 FinalSite 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARA � �JN: I hereby affrm untler penalry of perjury one o( the following declarations: ❑ I have and will maintain a certificate o( consent to self-Insure for vrorkers' compensation, as pmvided for �y section 3700 0! the Labor Cotle, for Ihe pe ormance of the work tor which this permit is issued. I have and will maintain workers' compensation insurance, as required by sectbn 3700 of the Labor Code, fw the peAormance of the work for which this pertnit is issued. My workers' compensation Insurance carrier and policy number are: /��l Cartier-� {�(I�f{- I�S C� (This seclion neetl irol be mmplefed d the peimrl is valuetl af one huntlred dollars (3100) oi less J Policy.Numbec-�bJ� 7 9/(� �.j D O ❑ I certify Ihat in the peRortnance of ihe work for which this permit is issued, I shall not employ any person in any manner so as to become subject to ihe workers' compensation laws of Califomia, and agree ihat i( I shoultl become subject ro the vrorker ' com nsation provisions of Section 3700 of the Labor Co ,.I INo h' c ly with these provisions. ��f U f nl's SlgnaWre Da�e ^� WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVER4GE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000�, IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, IMEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby aKrm thal I am licensed under provisions ot Chapter 9(commencinq with Sec[ion 7000) o( Division 3 of the Business and Professions Code, and my license is in full torce and eRect. �ic.p ' �t�SslO� ciasstt 'G`7� - 7/4 0 9 Contrac�or'sSgnawre" .__ Date . CONSTRUCTION LENDING AGENCY: ❑ 1 hereby aKrm tha[ there is a constructbn lending agency for the per(ormance of �he work fa which ihis pertnit is issued. (Sec. 3097, Civil Code). Lender'S Name: Lender's Address: $ignalure Dale OW NER-BUILDER DECLARATIONS: I hereby affirm lhat under penal�y of perjury that I am EXEMPT FROM THE CON7RACTORS UCENSE LAW tor the following reason (Sec. 7031.5, Business an0 Professions Code: Any cily or couNy which requires a permit to construct, alter, improve, demolish, or repair any simcture, 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 o! [he Contractors License Law (Chapter 9(commencing with Section 7000) of Division 3 of Ihe Business and Prolessions Code) or thal 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 Ihan five hundred dollars ($500).): ❑ I, as owner o( the property, or my employees with �vages as their sole compensa[ion, WILL DO THE WORK, and the slructure is not intended or oHered for sale (Sec. 7044, Business anC Professions Code: The Contractors License Law does not apply to an ovmer of property vfio builds or improves ihereon, antl who does such work himself or herself or through his or her own employees, provitled that such impmvements are not imended or oftered for sale. If, however, the building or improvement is sold within one year ot completion, the owner-builder will have ihe burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELV CONTRACTING WITH LICENSED CONTRACTORS to conslruct the project (Sec. 7044, Business and Professbns Code: The contractors License Law dces not appty to an owner of property who builtls or improves Ihereon, and who contracts for such pmject with a contracta(s) license pursuant to the Contraclors license Laws.). ❑ I am exempt under sec. Business and Protessions Code (or this reason: Signawre �ate 305'l-46 (3/0]) . Owner ID verifed by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verifcation of Ownership by (type of document, i.e. - properry tax bill or deetl�: DIVISION OF INDUSTRIAL SAFETV PERMIT CERTIFICATION: ❑ I hereby certrfy that no excavation (rve (5) or more feet in depth into which a person is required to descend, will be made in connection withwurk authonzed by Ihis permit, and [hat no building struc�ure, scaf(olding, falsewoM, or demolition or dismantling thereof, will be more than ihirty-siz (36) feet high. (Chap. 32, Grp 2, Ari 2, Sec. 341, Ttle 8, Califomia 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 ro do such vrork from the division. AOWicaN's SignaWre Division of Industrial Satery Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or tuture building occupant neetl to 61e and certify a Business Plan !or emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Califomia Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire DepaAment by every business which has at any one time during a reported year a quantiry of hazardous matenals 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 tempereWre and pressure�. 2. Does or will the applicant or present or �uture building occupant need to file a regisiration fortn for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of ihe Calitomia Health and Safety Cotle, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which aI any one time has on hand a quantity of awtely hazardous materials equal to or greater than a weight of 500 pounds, or a volume o( 55 gallons, or 200 cubic (eet of compressed gas at standard temperaWre and pressure). 3. Does or wi0 the applicant or present or fuNre builtling occupanl need to prepare an RMPP (Risk Management and Preven[ion Program (or acutely hazardous materials�? ❑ Yes ❑ No (Section 25534 of ihe California Health and Safery Code provides that the Costa Mesa Fire Department may require the preparetion, ceAification and (ling with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Seclion 25534 of the California Health antl Safety Code been lully complietl with? ❑ Yes ❑ No 5. Does or will the applicant or presenl or fuWre building occupaN require for the work which is the subjecl of this application a permit for such construction or modifcation fmm the Soulh Coast Air Qualiry Management Distric� or from any other air polWtion control tlistrict or agency7 ❑ Yes ❑ No (Section 658502 of the Cali(omia Govemment Code requires that Ihe requestetl infortnation be fumished on applications fa rwn-residential building permits). 6. Will any part of the faciliry to be construcled under this permit be within 7000 (eet from the outer boundaries o( a school? ❑ Yes ❑ No (It'yes", the facility must meel the requirement of Sections 25534 and 42303 of the Cali(omia Health and Safery Code). 7. If a pertnit from the South Coast Air Quality Management District or other air pollution contml district or agency is required tor the work which is the subject of this application, have all of lhe disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. Qf "yes", attach certificate of compliance from the appmpriate air polNtion conVol oKcer�. CERTIFICATE OF COMPLIANCE: I certily ihat untler penalry of perjury the information given above is correcL I agree to compty with all state laws and ciry ordinances regarding Hazardous Materials and Emissions. CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty ot perjury that I have reatl ihis application and state that the information given is correcL I agree to compty with all state lavrs and city ortlinances rela[ing to buil0ing construction, and auihorize 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 aWhorized by Ihis permit un�il Mal ins ection. ign reo! wn ) /te � 7 C Antl/orAut�onzetlApplit�anl � Oa�e � Applicant to fill in all spaeez within CITY OF COSTA MESA CONSTRUCTION PERMIT Address Address boreer lines ana sign all apOropriate tlecla TRACT NO. LOT NO. �BLD6 NO. ' TVPE OF CONSTRUCTION Phon � r �� ❑ NEW ❑ A�D ❑ ALTERATION � Any .�L� ❑ REPAIR ❑ CONVERSION ❑DEMOLISH License No. ❑ OTHER �ESCRIPTION OF WORK I hereby attirm that I am licensetl untler provi5ion5 of Charter 9(com- mencing wltn sectlon 7000) of Division 3 ot the Business antl P1012551005 COdC. d RIY IIC2052 IS IO fUll (OIC2 dOtl 2ff2CI. Litense Ia55 —� Lite e No ����y Data Si9nature �� � _-�� '7RKER5'COMPENSATION DECLARATION ereby affirm that I have a certificate of consent to selt-insvre or a :Ificate of Wo�ker5' CompEnsatiOn Insyyy��� nce, or a certifietl copy ..rereoi (Sett��P ry3 00, tab. C.). � , // � Policy No. `-� ��9�� � Comoany ��J �I�-ar ❑ Ce fietl copy is �ereby furnishetl. _ erUfietl copy is filetl with the city Builtling Division. EXEMPTION FROM WORKERS' COMPENSATION DECLARHTION (This SeCtiOn n¢Gtl not b¢ Cortlplet¢tl it the permit is for one huntlretl (E100) or less). I certi(y that in the performance ot the wo�k for which this permit is issuetl, I shall not employ any person in any manner'so as to become subject to the Workers' Compensation Laws of California. Da[e Signature NOTICE: If after making this tleclaration, you shoultl berome subject t0 the WOrkGrs' Comp¢nsation ptovisions of the Labo� Cotle, you must �orthwith comply with Such provi5ion5 or this permit Shall be tleemetl /¢vOk¢tl. CONSTRUCTION LENDING AGENCV 1 hereby affirm that there is a construction lentling agency for the per- fO�mdOce ot the work for which this permit is issuetl (Settion 309� Gv. C.). " - .. . Lentler's Name Lentler's Atltlress OWNER BVILDER DECLARATION - ' ' I hereby atfirm that 1 am exempt hom the Contractor's License Law for tbe'following reason (Section �031�.5 Business antl Professions Cotle: Any city or wunty whiCh requires a pe�mii to consVuct, al[er, improve, tlemolisM1 or'repair any structure, prior to its issuance, also re- 'res the applicant fo� Such permit to tile a si9netl statement that he cen5etl purivant to th¢ provisions of the Contracto�'s LicenSe Law apter 9(mmmencinq with Secilon �000) of Division 3 of the _..Slness antl P�dessions Cotle) or thaT he is exempt theretrorn antl the �i basis for the alleged exemption. Any violation of Section 7031.5 by any applirant for a permit subjects the applicant to a civil penalty of not more than five huntlretl tlollars ($500). ❑ I, as owne� ot the property, or my ernployees with wages as their Sol¢ Compen5ation, will tlo the wo�k, antl the structure is not intentletl or ofieretl for sale. (Section 7044, Business antl Professions Cotle: The Cont�acto�'s License Law doe5 not apply to an owne� ot a property wh0 bullds or imp�oves thereon, antl who tloes such work himself ar thrnuoh his nwn emolovees. orovidetl that such imorovements are not is soia wimin one yea� oi compieiion, me owner wiu nave me ouroen of p�oving he did not builtl o� imp�ove tor the purpose of sale). ❑ 1, as owner o( the property, am exclusively contractin9 with IicenSetl mnt�acto�s to construct the project (Section ]044, Business antl' Professions Code: The Contractor's License Law tloes not appry to an owner of property who builtls or improves thereon, antl who con- t�acts f�om such projects with a mntractor(s)� licesnetl pursuant to the Contractor's License Law�. ❑ I am eKempt untler Section B. & P. C. to� this reason Date Owner 1 hereby certifythat I have reatl this applicatian antl state that the above intormation is correcL I a9ree to comply with all city antl county artlinances antl state laws relati to construction, antl hereby authorize representatives f this city o Enter upon the abov mentionetl property fVor ' ip�ction os�s. � � Slgnature �� Date� Drivers' License or 55 � -'�//% _/ TYPE OF PERMIT � ❑ GRADING ❑ FOUNDATION ❑ STRUCTURAL ❑ TENANT ❑ ELEGTRICAL OPLUMBING ❑MECHAI ❑ OTHER PROJECT DESCRIPTION SQ. FT. OCCUPANCV_CONSTRUCTION TYPE VALUATION ZONE GRAOING CU. VDS. ACRES PLUMBING '"' PLAN CHECK- BATHTUBS SHOWERS ' TOILET$ VRINAL$ ' LAVATORIES DOVBLE LAVS KIT.SINKS ' DISHWASHERS SERVICESINKS SUMPS ' - F1.00R SINKS FLOOR DRAINS DRINKING FOUNTAINS INTERCEPTORS �CLARIFIERS SWIMMINGPOOL PTRAP WATERSERVICE ALTERATION GASSERVICE WATER HEATERS SEWERCONNECTIONS SOLARTANK SOLAR PIPING SVS. ISSUE FEE MECHANICAL BTU OUTPUT COLLECTORS PLAN CFIECK HEATING SVSTEM 0-100,000 BTU ANDDUCTING 100,000+BTU REFRIGERATION 0-100,000 BTU SYSTEM - 100,000 + gTU BOILERS BTU SVSTEM REPAIR,ALTERATION EXHAUSTSVSTEM MULTIPLE ISSUE FEE 1� CMF 0865-46 White-Builtlinq; Canary-Applicant; Pink-Accountinq; Goldenrotl-Assessor 1, ,�15375 9/IB/BI ZONING REGULATIONS ZONE REAR YARD (TO P/I PKG. SPACE REQ. STREET WIDTH ZONING APPROVED SPECIAL CONDITI01 ELECTRICAL PLNG. REF. � PROVIDED PARK FEE $ PLAN CHECK GENERATOR 0-1 KW_ 1-lO KW _ TRANSFORMER - APPLIANCE 30-SOKW_SO+�KW_ MOTORS � p-1 HP_1d0 HP _ - (INC.SOLAR) 10-50HP 50+HP_ FIXTURES " OUTLETS SWITCHES GAS TUBE SIGNS � � POLE LIGHTS PANELS - 'MAIN ISSUE FEE SUB AMP � � BV DATE SUMMARV OF FEES , , BUII.DING � PERMIT $ PLANCHECK $ PLUMBING 5� PLANCHECK $ E�ECTRICAL $ PLANCHECK $ MECHANICAL $ PLANCHECK $ � o � ��C���� SMIP $ PERMIT �, ISSUANCE $ GRADING b $ MICROFILM $ TOTAL FEE 8 � LE55 AD- VANCEPC $ FINALFEE $l�L__:�L CONSTRUCTION AND PLANNING POOL & SPA � APPROVALS Permit# Date Inspector pppROVALS Permit# Date Inspector 1. Temporary Electrical Service or Pole 43. Pool & Equipment Location � 2. Soil ipe-Un rgrn ' 44. Steel Reinforcement � 3. Electrical Conduit Utility-Undrgrn 45. Forms 4. Electrical Conduit-Undrgrn 46. Electrical Bonding . tee ein orce 47. Rough Piumbin & Pressure Test 6. Electrical UF R Grn 48. APPROVALTO COVER-GUNITE 7. Footings 49. Electrical Conduit-Undr rn 8. Foundation 50. Gas Pipe, ❑ Undr rn, Test 9. Water Pipe-Undrgrn 51. Backwash Lines P-Tra ❑ Undr rn 10. Structural Floor System 52. APPROVALTO DECK 11. Property Sewer Line & House Connection 53. Backwash & Rece tor-Final 12. Street Sewer Connection ' 54. Heater & Vent-Final 13. Rough Plumbing - � 14. Rough Electric-Conduit �• � �56. Electrical-Final 15. Rough ElectriaWiring "' � 57. Solar System-Final i 6. Rough Heating & Air Conditioning � encing & Access Approval 17. Ducts, in Structure - APPROVED FOR PLASTERING 18. Ducts, Ventilating 19. Gas Pipe-Rough &Test 60. POOL/SPA SYSTEMS FINAL 20. Roof Framing - 21. Roof Sheathin 22. Frame and Flashin NOTES: 23. Insulation 24. Lathing & Siding 25. Drywall Nailing 26. Plaster Brown �at 27. Electrical Power Meter-Final 28. Final Electric 29. Final Heating & Air Conditioning 30. Final Gas Pipe-Test 31. Final Plumbing 32. Water Service-Final 33. Gas Service-Final 34. Solar pomestic-Final 35. Landsca e S rinklin S stem 36. � � Sound Attenuation 37. Handicap Regulations 38. FINALSTRUCTURE&BUILDING 39. Special Requirements Completed 40. Electric Release to Edison 47. Gas Release to Southern California Gas Co. 42. CERTIFICA7E OF OCCUPANCY No: Date V. . 1 �� OWNER WAYCOTT�_DQN6T.n S�[ DATE 1-2C� JOB ADDRESS qQg�_Ceylon R�Art BUILDING PERMIT NO. 31i.-(�n . GENERAL CONTAACTOR ,,...„e,../l...tiae,.. VAT.iIF. S� .,n� �.. SUBCONTHACTOR 23460 COSTA MESA BUILDING-SAFETY DEPARTMENT P. O. BO% O V COBTA MEBA, CALIFORNIA For Applicanf to Fill /n Completaly TYPE OR PRINT Aoo Ef59 082 Ce lon Road COSTA MESA, CALIFORNIA ts•s�l.r.v ■ 6ETBACK LIH6 FROM NO. OP pLOOD. 0 91DE YARDI LEFT U� I R16HT U� DESCRIPTION OP WORK NEW � ALTERATIONI DEMOL SH REPAIR MOVIN6 BUILDIN0. �x 2p � NO.OF 61ZE 1 u ROOMS BTOR169 COVERINGWALL � COVERIN6 COI'. Pl.asti � existing building structure FIRE FEE RECEIVkl� JAN z s �yu5 �„J FINANCE DEP7. CITY OF COSTA MESP APPLICATION FOR PERMfT BUILDING For Oifice Use Only RHCHIPTNO. /��Pj ZONING NO.OR UB60PNF PLANB � OUILDIHO v moHl.6 �l / % �//J r A. P. NO. �� %' / � J � � NOTE: NO EAVE OVERMANO 6HALL BE LE93 THAN 90' TO SIDE d REAR P. L. Pr1VH9 ALLOWED (U.B.C.REQUIREMENT: YARD9APPROVED VARDSAPPROVED MAIN BUILDIN6 ACCESSORY BUILDING ( FROM C/L SiREEL) . . OISTANCE BET. MAIN BLD69. VAR. � BET. MAIN 8 ACCESS. BLI DATE —Z�—G 7 � H I4 Sp.FT. � 1 HEREBY ACKNOWLEOOB THAT I HAVQ RFAD TN�B APPLICATION TXE �MOUNT BHOWN UNDER V�LU�TION IB POH TH¢ f •ND STATB TXAT iHH ABOVB 19 CORRfiCT AND AOREB TO COM. PURPOSE OF eeTwBL18HINO A PERMIT PEE ONLY. 0 PLY WITH �LL CITY OROINANCBB AND 6TAT8 LAW➢ H[OULhTIN4 ypLUATION ((� /� l`p'. BUILOINO CON9T U N. q SIGNATUREOP PERMIT FEE $ « m PERMITTE s l n0 �� o AUTHORIZ6O AGfiNT / °' COSTA MESA BUILDING•SAFETY DEPARTMENT P.O.BOX 319 COSTA MESA,CALIFORNIA fOR APP[/CANT TO F/LL /N COMPLETELY TVPE OR PRINT BUILDING '^ ADDRE55 tX/�� /DA � , :- - � �� d �`j � _ � � ,', d E ip..� , f-�. W/Ar 26 �rr� �' " F„��ft�E DEPT. �.Ii". (lt: (`f1Sin 6�"G. APPLICATION FOR PERMIT BUILDING COSTA ME$�C. CALIFORNIA FOI� OFFICE USL ONLJ S camore Land. Co • I RECEIPT NO. I PE P. OWNEft Y MAIL 10835 Santa Monica B�Vd.• RECEIVED BY DATE FECEIVE� �,j� T I5: ADDRE55 yS-j - IIIA� [ �ir� LOS Angeles NoBL'23287 BUILDING � nooaess .-s i ARCHITECT ��c. COSTA MESA. CALIFORNIA OR ENGINEER L.C. Ma OY NO. ADDRESSyyO1S S. P�aMOUTSt BIVd.. FIRE ZONE i STATE � APPRQVED CONTRAQOR Mal ren Const�,�. �,o fJ BY AooRE5510835 Santa Monica Blvd.. [scaiPliorv I NOT � i I BLOCK ITRACT33() ZONE �/ I "j-i%'/irlCL( �ATE ZONING NO.OF USE OF NEW PLRNS BWLDING OF LOT 11'2. V � }[ p2. fj'Z I NO. OF BlOGS. O yqRDS � rvow orv �oi REQUIRED USE OF ICENTER LINE ST.) EXISTING BLDG. FRONT /-.� SET9ACK LINE FROM /'' � (— cErulEa or srREEr ��i �7 O REAR YARD ii � v cinr \ ILEFT S� I RIGHT /� DESCRIPTION OF WORK � v EVES / ALLO W EO FT. IN. FT. IN. FT. IN. / FT. Il� ♦ REPAIR I IIMOVING I s i�=o�"G 1693 "ao°oMs 6 EXTERIOR WALL ROOF COVERWG S'tllCCO ICOVERINQ�i USE OF 6UILOING ANO WORK TO BE PE Dwellinq=new const ._� � 2 h—., 1 I HEflEBY ACKNOWLEOGE THAT 1 HAVE REpO THIS APPLICAT�ON AND STATE THAT THE RBOVE IS CORPECT AND AGREE TO COM- THE RMOUNT SHOWN 11NDER VpLtIATION IS FOR THE PLY WITH RLL CITY ORDINqNCES TND STATE LRWS REGULATING PUflPOSE OF ESTABLISMING q PERMIT FEE ONLY. BUIIDING CONSTFVC N. �/'J VALUATION SIGNATURE O_ %- L � PERMIT FEE $ PERMITTEE—_-a��� • g /// G�� � PLAN CHECK $ / � L _]� � i AUTHORRED AGENT ,� [� TOTAL FEE $ �� . .