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Home My WebLink About104 CLEARBROOK LN - Building PermitsCITY OF COSTA MESA - r ; BUILDING DIVISION � DEVELOPMENT SERVICES DEPARTMENT / PERMIT PERMIT NUMBER/ B98-01912 (714) 754-5273 • Fax (714) 754-4856 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 104 CLEARBROOKLN Status: ISSUED Suite: Applied: 10/22/1998 Vicinity: Issued: 10/22/1998 Parcel Nunmber: 41914105 Zoning: Applicant: KIDWELL, JOHN Address: 923 N. LOGAN ST Phone: -794-558-3707 NOTES 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 the work authorized under this permit 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 final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 SANTA ANA Zip: 92701 PLANNING% ZONING Owner: NLIGENT.�RIT W C TR J) = Address POBOXS245 Phone . .._ ... /,�FULLERTON,CA ': Zip. 92838 SETBACKS SANTAANA'ROOFING contractor: % Front ',0-0 Address: 00923 N. LOGAN'� - Left 0-0 Right 0- 0,! Phone: SANTA'ANA CA Zip:,, 92702 ACCESSORY License v 463596 - `..r ��` Aich / Eng -f - •,,,..��'. < ,. \, Address -' -Phone:_ - _ PARKING Zip: .. . Required: 0 License: .. - •;�', SCOPE OF PERMIT \ -4-PLON,TOP •I i ,REMOVE (SPUDDING),ROCK TO MEMBRANE, THEN INSTALL NEW W/CAP SHEET. 15 -YR - ,, ;B -U ROOF. .A, FEE.SLIMMARY \ r� Plan Check: $0.00 — —_ —Calc Valuation $4,000.00 Permit: $87.25 - Claim Valuation $4,000.'00 SMIPRes. $0.50 SMIP Com:: , $0.00 \'-.'Other: . $0:00 Inspection: $0:00 Total: $87.75' NOTES 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 the work authorized under this permit 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 final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 PLANNING% ZONING SETBACKS MAIN STRUCTURE Front ',0-0 Rear 0-0 - Left 0-0 Right 0- 0,! ACCESSORY Front 0-, 0 ` =_ { Rear 0-0 Left 0-0 Right-;;, 07 '0' PARKING Existing: 0 Required: 0 Proposed: 0 NOTES 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 the work authorized under this permit 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 final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty at perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Cade, for the performance of the work for which this permit is issued. 4;f 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carder and policy number are: Carrier: L K, /��'1 ('+ Ct �(� Policy Number: WC / — 65YOO (this section nee not be completed it the permit is valued at one hundred dollars ($100) or less.) ❑ 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, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Cade, I shall forthwith comply with these provisio Applicant Signature: �— Date: _ _/O —Z 1 —5-e WARNING: FAILURE TO SECjWeV ORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CAVIL PINES UP TO ONE HUNDRED THOUSAND DOLLARE($100. ), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is in full force and effect. Lic. a C 3 9 — d 3 G Class p Contractors Signature: Date:— CONSTRUCTION ate:_ CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, 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 of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that 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 than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. It, however, the building or improvement is sold Within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, talsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, An 2, Sec. 341, Title 8, California 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 to do such work from the division. - Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials 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 temperature and pressure). .................................................................................................................................................................................................................................................................................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials 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 temperature and pressure). .................................................................................................................................................................................................................................................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing 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 requiretl, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No .................................................................................................................................................................................................................................................................................... 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication appermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes CJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). .......................... .............................................................................................................................................................................................................................. I........................... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .................................................................................................................................................................................................................................................................................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which Is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ............................................................................................................................................................................................................................... 8 (If 'yes", effech certificate of compliance atr pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize 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 authorized by this permit until final inspection. Sign ure Le r(s) , to An r oriz plicant Date 00➢E_/. INSPECTION TYPE - PATE INTITI/LS CODEC INSPECTION TYPE PATE I!®A64 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 264 Final Demolition 250 Final Building/Occupancy City of Costa Mesa i �� C Building Safety Department CERTIFICATE OF OCCUPANCY NO 21 P. 0. Baz 317 Costa Mesa, California The Building located at 104 e1nprjlro Tnnei jjnifie Rs C has been inspected and found to comply with the provisions of all City of Costa Mesa Ordincnces applicable thereto for a Group j;,i' — Occupancy. Use of Building S'rlplexy.Lth attached gara—Se -- .egal Description 7141-3h3-03 - (See reverse side for Metes and Bounds) Building Permit No. mgr is Electrical Permit No. 232119 Plumbing Permit Nc.--4 '� Floor Load Signs have been installed as Room Capacity Signs have been instaled as required under Sec. 2308 U. B. C. required under Sec. 3301 (1) U. B. C. 17050. CERTIFICATE OF OCCUPANCY. (a) No apartment house, hotel, or lodging house shall be used or occupied until the owner or operator has been issued a valid certificate of occupancy by the enforcement agency. (b) A new certificate of occupancy shall be obtained whenever there is a change in: 1) Occupancy classification of a building or portion thereof 2) The number of apartments or guest rooms 3) Ownership If Group H Occupancy, number of apartments and/or guest rooms as required under Sec. 17050.1 (d), California Administrative Code, Title 8, Chapter 9, Article 8. Number of apartments 3 and/or guest rooms SUED TO: Building Official C rARRRCrX I.AA1r1 CCRP(1RAT10N by Date march a5, This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 306 (e) U.B.C. Forrn sn34—inc-11-63__s-13 r Applicant to fill in all sCaces except those within heavy border lines and sign all appropriate declarations. - - 9378 110/03/B4 7.00 TL' CITY OF C STA M SA 7A21 -CONSTRUCTION PERMIT PERMIT NO. PIs 3 TRACT NO. . LOT NO. uNlrNo: Prooct Address - _ - TYPE OF CONSTRUCTION NEW ADD _ ALTERATION REPAI R ❑CONVERSION ❑DEMOLISH ❑OTHER DESCRIPTION OF WORK/USE OF BLDG. - - Applicant'sMail Address Owner's Name Phone-.2�, Address ' " •, A.P.# Zone S Main Building: Accessory Building: Arch/Eng. License No.- Address - TYPEOF PERMIT 0 GRADING LJ FOUNDATION 11 STRUCTURAL '❑ TENANT ❑ ELECTRICAL ❑ PLUMBING, ❑ MECHANICAL - ❑ OTHER T Front - .O B - Rear _ N Contractor's Nam Phone Address(mailing) �L[ City.Licli No. `lIJ- - LICENSED CONTRACTOR DECLARATION I hereby, affirm that Iam licensed under provisions of,Charter 9 (commencing with section 7000) of Division Of a Business and Professions Code, and my license is in full force antl of ec t License Class i license No. A C Right - I N :PROJECT DESCRIPTION 50. FT. occuPArvcv CONSTRUCTION TYPE - VALUATION$ ZONE GRADINGCU.YDS. ACRES ' S Left. G R. -' Ping. Ref. # - Parking Req./Provided. - E". Remarks: 7 i Planning Notes: - ' I� M - _ T' S. PLUMBINGFEES - _ ' Date • - Signature - , Bar Sink Showers ' ELECTRICAL FEES WORKERS' COMPENSATION DECLARATION I I hereby affirm that I have a certificate of consent to self -insure or a certificate i i` •of Workers' Compensation Insurance, or a certified copy thereof (Section 800, Lab, c.) Backflow Preventer Service Sink -Automatic Washer Transformer ❑ 15-50 KW - Backflow Irrigation Sewer Cap olicy No. Company BCertified copy is hereby furnished. Construction POIe _Sub. ❑ 50+ KW - Bathtubs Sewer Connection - Cooking Unit Meter ❑up to 100 amps I Certified copy is filed with the city Building Division. Date Applicant - EXEMPTION.FROM WORKERS' COMPENSATION DECLARATION Clarifiers- _ Solar Collectors _ _ Dishwasher _ Meter ❑Over 100 amps - - - (This section need not be completed if the permit is for one hundred ($100) or Iess)tI I certify Ithat'in the performance of the work for which this Permit is issued, I shall not employ any person in any manner so s to become subject to the r WorkeWorker C p nsa ion, Laws of Ca lif oln fa„ .'i✓L-IF Date �� ut . Dishwasher I Solar Piping Dryers ❑Gas ❑Electric Sub Panel - Drinking Fountains Solar Tank Fan Motors ❑0-1 HP ❑1 % - 8 Floor Drains Swimming Pool w/SPa F.A.U. 1 - Inc. Solar, ❑9-15 HP ❑16-15+ NOTICE: I , fter eking this declaration, you should become s ject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be. deemed revoked Floor Sinks Urinal - - FltUf¢5 -- - x Microwave`" - Gas Service 'Bntieb- - 'Water Closet '� Device Boxes Pole Light ' CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction' lending agency for the performa cc Z of the work for which', this permit is issued (Section 3097 Civ. Lender's' Name, n erceptors - Water Heater Outlets Range Kitchen Sink - Water Service Switches Sign ' Lender's Address°• OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5 Business and Professional Code: Any city or Lavatories - Garbage Disposal ' 9 p Standing Sections P -Trap p - Generator ❑0-5 KW ❑5-15 KW Trash Compactor county which requires a permit, to construct, alter, improve, demolish or 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 Contractor's License Law (Chapter -9 (commencing with Section 7000) of Roof. Drains - Division 3 of the Business antl 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 nalty of not more than five hundred dollars ($500). - I;-aS owner of the property'oi my employees with wages as their sole W$ W. - - Reinspection Fee $15 - Issue Fee - 3 Reinspection Fee $15 Issue Fee $ 3 fIlliliallit compensation, will do the work,'and the structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractor'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 employees, provided that such improvements are not intended or offered for Sale. If, however, the building or improvement is sold within one year of com- pletion, the owner will have the burden of proving he/she did not build or im- move for the purpose of Sale). L I, as owner of the property, am exclusively contracting with licensed con- tractorSto construct the project (Section 7044, Business and Professions Code: The Contractor's .License Law does not apply to an owner of property. who builds or improves thereon, and who contracts for such projects with a con- - MECHANICAL FEES Boiler died Or Type I ❑ Canopy Type I I ❑ DEVELOPMENT SERVICES REQUIREMENTS: Zoning Approved By Date Building Approved By Date ,�, ^1� ) Application Issued By WA& Date l 012) Duct - Under Ground Duct - Structural Refrigeration System - ❑0.100,000 BTU ❑100,000 BTU _ Duct- Ventilating - I 'SUMMARY OF FEES Exhaust System ❑ Multiple ❑ System Repair/Alteration 1 -h 1 tractor(s) license pursuant to the Contractor's License Law). I am aware that proof o// their Worker's Compensation insurance should be provided to me., ❑I am exempt under Section B. & P. C. for this reason BUILDING,PERMIT $ - SMTP. $ ; PLAN CHECK $ PERMIT PLUMBING • C(ISSUANCE $ PLAN CHECK 25% $ ENERGY P.C. $ ELECTRICAL $ GRADING $ PLAN CHECK 50% $ 'MICROFILM $ MECHANICAL' $ TOTAL FEE $' PLAN CHECK 25% $ Firepl/Fact. Bit. ICBO # ' Date Owner - I hereby certify that I have read this application and stofe that the above ' Information is correct. I agree to comply with all City and county ordinances and state laws relating to building construction, and hereby authorize repre-i f sentatives othis city to enter. upon the above-mentioned pro party for inspection purp ses. f Signature 'Date Dri versrLicense or SS Heating System & Ducting ❑0.100,000 BTU 0100,000BT peinspection Fee $15 Issue Fee $ 3 CMF 0865-46, rev. 4/84 - Applicant: Pink - Accounting; Goldenrod - Assessor - - - - Al Ah CONSTRUCTION AND PLANNINGMr AOPROVALS, Permit# Date Inspector] POOL & '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 - - i 56. Rough Plumbing & Pressure Test , 6. Electrical LIFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit-Undrgrnd. f 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 Electrical -Conduit - - 66.- Solar System -Final - - 16. Rough Electiic Wiring 67. Fencing & Access Approval - 17. Rough Wiring Sign, -- 68. APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69., POOL/SPA SYSTEMS FINAL , 19.1 Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit# 20. Rough Factory Fireplace 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 'OGas ❑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 PREY. 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. FinalHeating & Air Conditioning 35. Final Gas Pipe -Test L¢p - 36. Hood or Canopy. 37. Final Factory Fireplace 38. Final Plumbing ja(a�•v`i LrtL' - 39. Water Service -Final - 40. Gas Service -Final - 41. Solar Domestic -Final 42. Backflow'Preventer .I 43. Backflow'.lrrigation, .- .,.. -. (, 44. ,Landscape Irrigation System I - 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 ' � u COSTA MESA BUILDS _ _.'°3AFETY DEPARTMENT P. O. BOX 317 COSTA MESA, CALIFORNIA For Applicant to Fill In Completely E 7, ^ PRINT [ADDRESS ILDING UILDCMESA, CALIFORNIA �B��bRoe.i�s-�A� _ ® MAIL I — _ SIZE . OF LOT/ 1A. ' J� a�SH , 'NOW ON LOT USEISOF EXTING BLDG. SETBACK LINE FROM _ CENTER OF STREET REAR YARD SIDE YARD LEFT 'RIGHT DESCRIPTION OF WORK BUILDI � SIZE O - EXTERIOR W/ COVERING BE FEE -..RECEIVED 17 1964 FINANCE DEPT. CITY Of COSTA MESA APPLICATION FOR PERMIT BUILDING For Office Use Only RECEIPT NO. I RTrtRq ryty., RICIN [Y BUILDING lof'7 PPROVED✓ Y DATE ZONING NO. OF UEE OF NE J S PLANS BUILDING _C�A A, � A. P. NO. I T ' J NOTE: NO SAVE OVERHANG SHALL BE LESS THAN rr 30' TO SIDE a REAR P. L. EAVES ALLOWED (U.B.C. REQUIREMENT) YARDS APPROVED YARDSAPPROVED MAIN BUILDING'. ACCESSORY BUILDING I HEREBY ACKNOWLEDGI3 THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE 1E CORRECT AND AGREE TO COM. PLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING BUILDI NO CONSTRUCTION, SIGNATURE OF PERMITTE AUTHORIZED AGENT iT / )"-,11 A �/ VAR. * DATE THE AMOUNT SHOWN UNDER VALUATION IS FOR THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. VALUATION PERMIT FEE S O ? $ 61 l l C E /` Y 1 TOTAL FEE $ ` 7- F