HomeMy WebLinkAbout2824 DRAKE AVE - Building Permits� •3
( ., CITY OF COSTA MESA
4�,OSYpMFS9 BIIILD/NG DIVISION - �
F�8 77 FAIR DRIVE. COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • www.costamesaca.aov
� � FOR INSPECTIONS CALL: (714) 754-5626
�'"°^°�°� PERMIT NUMBER: B11-00354
PERMIT TYPE B ROOF2 STATUS: ISSUED
APN: 14130103 DATE ISSUED: 10/17/2011
ISSUED BY: KJB
JOB ADDRESS: 2824 DRAKE AV CM� Suite/Unit:
Viciniry:
Squares: 2200 Valuation: $6,000.00
�%i''i
SCOPE OF WORK: TEAR OFF EXISTING ROOF. REPAIR/REPLACE SHEATHING AS NECESSARY. COVER WTIH CLASS A 30 YEAR
COMP SHINGLES. ROOF PITCH IS 3:12. INCLUDES ATTACHED GARAGE. APPROX 2200 S� FT �
NOTE:RESIDENTIAL RE•ROOF: Final approval of permit shall not be granted until access to dwelling unit(s) is provided for
verification of the installation of smoke and carbon monoxide alarms by the City Inspector. See Attachment w/lnspection Card
OWNER: NEWAYNO, DIANE
PHONE: � 949-293-8101
r.
APPLICANT: JORDAN, STEVE
PHONE: 714-744E577
CONTRACTOR: JORDAN ROOF COMPANY
Address: 915 W COLLINS AVUnit:
City/State/Zip: ORANGE, CA 92867
ARCHITECT:
ENGINEER:
FEE SUMMARY
�Reroof Plan Check:
F2eroof Permit Fee:
Reinspection Fee:
Bldq Std Admin Fund
AL FEES
$0.00
$125.25
$0.00
$1.00
Address: 2824 DRAKE AVE
City/State/Zip: COSTA MESA, CA
Address: 915 W COLLINS AV
City/State2ip: ORAN6E, CA
License No.
License No.
PHONE:
HOURS FOR CONSTRUCTION ACTIVITY; EFFECTIVE 311!
Monday lhru Friday - 7:00 am thru 7:00 Dm. Saturdays - 9:00 am thru 6:00 pm.
New Years Dav. Memonal Dav. Indeoendence Dav. Labor Dav. l
License No. 406783
714-744-6577
CELL:
PHONE:
PHONE:
Unit
Unit: :
- PER CMMC Sec. 13-279
tietl all hours - Sundays and the following Federal
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Cali(ornia statutes and related
regulations. (Ord. No. 92-28. § 1, 72-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorized under this 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 oblain inspections and final approval will result in the expiration of this permit.
CQUE/ INSPEGTONTYPE D�T IN RL GOOE1 INSPEC110NTVPE �lE INRilALS
1816 Fized System Final Fire Prevention 206 Final Mechanical
126fi Pool Spa Finat 1 208 Final Plumbing
200 Final Re-Roof , �(._I_.��'! R� 210 Final Electrical
201 Final BIocWReWining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final DemoliUon 25U Final BuildinglOctupanty
WORKERS' COMPENSATION D&CLARA710N:
I hereby aKrm under penalry of perjury one of ihe lollowing declarations:
❑ I have antl will maintain a ceryificale of consent to self-Insure for workers'
compensation, as D�o��ded for by section 3700 of the Labor Code, for the
performance o( lhe work for which (his permit is issued.
❑ I have and will maintain workers' wmpensation insurance, as required by
section 3700 0( the Labor Cotle, fOr the perfortnance of the vrork for which this
permit is issued. My workers' cbmpensation Insurance carrier and policy
number are: /'����/,v�' �p�
Carrier. (--W'�`��r�/Y'V
(This SecAon ricN not D�e m+�m7�pn'efetl OfM1g pemH u vdluM at me n�nCretl49ars ftf00) orkss )
Policy Number: (-/�y%' ���
❑ I certiry that in the pertortnance of the work for which this permit is
issued, I shall nol loy any per6on in any manner so as to become subject
to the workers' nsation laws ot Califomia, and agree that if I should �
become subjec t workers' compensation provisions of Section 3700 of
the L bor Co , I I forthwith cpmply with lhese provisio s.
� /4/7/l
pl naWre ate
WARNING: FAILURE TO SECUR� WORKERS' COMPENSATION COVERAGE
IS UNLANIFUL AND SHALI SUBJECT AN EMPLOVER 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, INTEREST, AND
ATI�ORNEY'S fEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensetl under provisions ot Chapter 9(wmmencing
with Section 7000) of D� ision 3 pf the Business and Professions Code, and
my license is in full ( i ntl eHect.
Lic. 4 Gass #
ie ry ii
nh t s gnawre ate
CONSTRUCTION LE DING AGENCY:
❑ I hereby affirtn Ihat there is a construction lending agency (or Ihe
peAortnance o( Ihe vrork for which this pertnit is issued. (Sec. 3097, Civil Code).
lenders Name:
Lenders Address:
Signalure Date
OW NER-BUILDER DECLARATIONS:
I hefeby 0ffrm lhat Under penalty o( perjury �hai I am E%EMPT FROM THE
LONTRACTORS LICENSE LAW for the following reason (Sec. 703L5,
Business and Professions Code: qny ciry or wunty which requires a permit ro
construct, alter, improve, demolish, or repair any sWCWre, pnor to its
issuance, also requires the applicaN for such permit to fle a signed statement
that he or she is licensetl pursuant to the provisions of Ihe Contractors
License Law (Chapter 9(commencing vn�h Section 7000) of Division 3 of the
Business antl Protessions Cotle) or that he or she is exempt iherefrom and
Ihe 6asis for ihe alleged exemp�ion. Any violation of Section 7031.5 by any
applicant (or a permit subjecis the applicant to a civil penalty of not more than
fve hundred dollars (5500).):
❑ I, as owner of the pmperty or my employees with wages as iheir sole
compensalion, WILL DO THE WORK, and t�e structure is not intended or
offered for sale (Sec. 7044, Business and Professions Code: The Contraciors
License Law does not apply to an owner of property who builds or improves
thereon, and who does such work himsel( or herself or through his or her own
employees, provided that such improvements are not intended or oHered for
sale. If, however, ihe building Or improvement is sold within one year of
completion, the owner-builder will have lhe burden ot 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 GONTRACTORS to construct the project (Sec. 7044, Business and
Professions Cotle: The wntractors License Law does not appty to an ovmer of
pmperty who builds or improves thereon, and who contracts (or such project with
a wntractor(s) license pursuant to the Contractors License Laws.).
❑ I am exempt under sec.
Business and Professions Code for Ihis reason:
Signamre Date
305]-06 (3/0])
Owner ID verifed by driver's iicense. ❑ Yes ❑� o
Driver's License No. ' Expires:
Verification of Ownership by (rype of document, i.e. - pmperty tax bill or deed):
DIVISION OF INDUSTRIAL SAFEN PERMIT CERTIFICATION:
❑ I hereby certily that no excavation fve (5) or more feet in depth into which a
person is required to descend, witl be made in wnnection vrith work authorized
by this permiC and that no building sWCWre, scaHolding, falsevrork, or demolition
or disman0ing thereof, will be more than thirry-six (36) feel high. (Chap. 32, Grp
2, Art 2, Sec. 341, Title 8, Califomia Administrative Code).
❑ A5 owner-builtler, I will not employ anyone to do vrork which vrould
require a permit from the Division of Intlustnal Safety, as nateC above, unless
such person has a permil lo do such work from the division.
Appl¢anlb SiB�alure
Division o( Industrial Safery Permit Number. _
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the applicant or preseni or future Duilding occupant need to fle and
ceAiry a Business Plan tor emergency response to release or threatenea
release of a hazardous material? ❑ Yes ❑ No
(Seclion 25505 of the Califomia Health antl Safety Cotle requires, with some
exceptions, t�at a Business Plan be filed with the Costa Mesa Fire
Department by every business which has at any one time dunng a reported
year a quantity of hazardous matenals equal to or greater than a weight of
500 pounds, or a volume of 55 gallons, or 200 cubic (eet of compressetl gas
at standard temperaNre and pressure).
2. Does or will the applicant or present or future builtling occupant neetl to file
a registration form for acutety hazardous materials? ❑ Yes ❑ No
(Section 25533 of ihe Califomia Health and Safery Cotle, vnt� some
exceptions, requires regis�ration with the Cos[a Mesa Fire Department by
each business which at any one time has on hand a quantity of acutely
hazardous matenals equal ro or greater than a weight of 500 pountls, or a
volume of 55 gallons, or 200 cubic feet of compressed gas at stantlartl
temperalure and pressure).
3. Does or will the applicant or present or fuNre building occupant need to
prepare an RMPP (Risk Management and Prevention Program for acutey
hazardous materials)? ❑ Yes ❑ No
(Section 25534 0( lhe Califomia Health and Safery Code pmvides that the
Cosla Mesa Fire Department may require the preparation, certifwtion and
filing with the Fire Department of an RMPP by businesses which are required
[o register acutefy hazardous matenals with the Fire Oepartment.
4. If an RMPP is presently required, has Section 25534 ot the California
Health and Safe�y Code been fully complietl wi�h? ❑ Yes ❑ No
5. Does or wiil the applicant or present or future Duilding occupant require for
the work which is lhe subject of this application a permit for such constmction
or modification from the South Coast Air Oualiry Management District or from
any other air pollution contml disUicl or agency? ❑ Yes ❑ No
(Section 65850.2 of the Califomia Govemment Cotle requires that the requested
in(ortnation be fumished on applications for non-residential building permits).
6. Will any part of the faciliry to be consWctetl under this permit be vnthin
1000 (eet from the ou�er boundaries o( a school? ❑ Yes ❑ No
(If "yes', ihe facility must meet the requirement of Sections 25534 and 42303
of Ihe Cali(ornia Health and Safety Code).
7. If a permit from the South Coasl Air Qualiry Management District or other
air polWtion control district or agency is required tor the work which is the
subject of lhis application, have all of the tlisclosures prescribed by Cali(omia
Health and Safery Code Seclion 42303 been made? ❑ Yes ❑ No
8. Qf'yes', attach certifcate o( compliance from the appmpriate air pollution
control oKcer).
CERTIFICATE OF COMPLIANCE: I certify lhat under penalty ot perjury Ihe
information given above is correcL I agree to comply with all stale laws and
city ordinances regarding Hazardous Matenals and Emissions.
SgnaNre ua�e
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certiry under penalry of perjury lhat I have reatl this application and slate that
ihe infortnation given is correcL I agree to comply wit� all stale laws and ciry
ortlinances relating to building consUuction, and authorize representatives o(
the City ot Costa Mes to enter upon the above-0escribed property for
in5peciion purposes./a �e not lo occupy or allow occupancy of any building
authonzed, by this p�f til (nal inspection.
ate
/orr �,
ate
4." '
�iCtil(�Cil�lll�
Jt c.��identird A!lerruinns
r� ��;��� r,:��„�: .Cii�1N6 �FW6t�IN0
CF-IR-ALT
(Pa�;e ] ot'S)
Clim:ne Zune H ' n � K of Stories
� �paque Sw'face Detail5 �ur the fun•ed portinned of Mass Wnlls see �urrin{; Strips Cunsvuction'1'nble beloa•. �
-�A I !7 I C I D E� ' F C H � I� d
Tag/ I Assembly Name
1D� orTv�e�
No�e:
Material
and Size�
U- JA4 Tnble Cavity
ector° Numbeis R-value
see Paxe JA4-3 arcd Equolion 4-1. F
lnsulation I Assembly I Assembly
R-VaWe' Cell Valuee U-factor9
use
1. Fa� Tag/ID indicare �he idemifica�ion name that ma�ches �he building plans.
2. lndicme the Assemblr Nome or type: R00%/Cei(ing, Walls, Floors, S(abs, Craw/ Space, Daors and e�c...lndicate (he Frame rype and Size: Far
Wood, Metal, Meral Buildings, Mass, enter ?z4, 2z6, or e�c... see JA4 for otherpossible (ramc rype assemblies.
3. Emer �Le �hickness fa' mass in inches or Spacing benveen fi�aming mem6ers enter; 1 G"or 24 "OC,- ar O(her• jor af/ odier assembly dra�criptian
�vclr as Conc+rte SondwicL Panel, Syandrel Panel, Logs, Su�aw Ra/e Pane! and e�c.... ,
4. Based on U�e Clima�e Zone; emer ihe Smndard U facior jrom Table.151-l�, C m� U for each d�eren� assernLlp Name or type.
5. Enrer �he TabJe numGer �ha� closelp resemb[es die yroposed aaa�emblr.
G. L•mer dre 2-value tlial is being insmlled in the wall canim a� Le�ween 1he (�nming; mherwise, emer "0 ".
7. Gnier ds Continuous /ns�dation R-value%r the propased ussembly; nlhenvise, emer "0 ".
d'. L•mer �he rnH� mid cnfunm ojihe U.(acmr valuc based on Cnlumn FTable Number and emer �he Asxern6fy U facmr in Column J
9. The Propnsed Asa�emLh• U fnclnr, Cn(umn J, nmsl Le equol m ur less Jmn d:c StnndnrA U-�ucmr in Cohinu� E m compl��.
FwTin Strips Cons[niction Table for Mass VJalls Only
A IS ' C U G � G FI I ,I IC 4 M
I'roposed Prupertiea oT Masunry :�nd Concrete Added Interinr or Cxieriur hisulatiun
N'alls I�rum Ne(erence in I�un•ing Space IYum Re(cr�ncc
Juint A i icndix'1'able 4.1.5 4.3.C. 4.3.7 .Ininl A t�endix'1'nblc 4.3.13
� = � R � t v
� p � GL �
Asu:mbly �' j �`c_ ° � �" o y;b 'O a"b Pinal
L� U. m 'O C � '��u
Mass Namc or lA4 Toblc �� ^ ;, � � E E o 'E , a p � A Asscmbly
Thickness' 9' r' Numbcr < � _� c � „° a a�" t� U-fuctorG'� Commem
I
I I I
Regi.sirwiai Number: liegisiruiion Uaie!lime: NE2S Prnvider:
2(I(l6' Residential Compliunce Form,r �l ugus� 2009
Prescri tive Certificatc of
Resirlentin( A[terations
/ Prqecf Namc: '�
�.
nce: Residential
Climn[e Zone
.F-1R-.ALT
Pa�e 3 oT 5)
H of Smries
ROOPING 1'RODUC7'S (COOL kOOFS)§157(pl2
When Uie nren nf erferior rnof.vvjare tn Ge replaced rxceeds mnre lhan 50% of Nie uisting rnof qren, or rqore tl�uu 1,000 j, �okicliever is
less, the ncin ranfiug aren iuna7 mee( (he rnofing prnduc( "Coo/ Rnof' reqnircreenrs nj§152(h)/Hi, I52(6J 1Hii, ar l S2(b)1Hiii.
Check npplrcable udernaJive a� ercepliau Gelow if ihe moJaGernlian is ezempl frnm rhe raofing pinduc� "Caol Roof' reqxiren+ents. Nnte: !ja
nne af (hc u[ferna(ives or rxcep�ion Gelow is checked, ihe Aged So/ar ReJlecmnce and Thermu/ Eminance reguirements jor roofing praducts in
,�'( ItY(i) are tto/ appficn6le. Uo no( ftll lable be(om.
Not RequireA in Climate Zones I-12, 14, nnd 16 with a Low Sloped. Less or 2:12 pitch. "
No� Required in Climate Zones I thmugh 9 and 16 with a Steep-Sloped Roofs (pitch greater Ihnn 2:12) and product unit weighi less
Alterna�ives to §752(b)1 Fli nnd §l52(b)Hii, Stecp-slape ruof (pitcli > 2:72J
� Insulation witl� a Ihennal resistance of at least 0.85 hrft��OF/Btu or at least a 3/4 inch uirvspace is added m the roof deck
ovcr an auic; or
❑ Existing ducts in the attic are insulated and sealed according to §151(Q10; or
.❑ In climate zones 10, 12 and 13, with 1 ft of free ventilation area of attic ventilation for every I50 ftZ of attic Floor area, and
where at least 30 pereent of Ihe free ventilation area is within 2 feet venical distance of the roof ridge; or
❑ Building has at least R-30 ceiling insulation; or
❑ Building has radiani bartier in Ihe attic meeting the requirements of §151(�2; or
❑ Building has no duc�s in lhe attic; or
O In climate zones 10, 1 I, I3 and 14, R3 or grwter roof deck insulation above vented attic.
Gxception to §L52(b)1Hiii, Low-slope roof (pitcl� 52:12)
❑ Building has no ducis in [he attic. �
❑ RooFmg area covered by building integraced; phomvoltaic panels and solar thertnal panels are exempt fmm ihe below Cool Roof criteria.
❑ Roof constructions that have thermal mass over the roof inembrane with at leas[?5 Ib/ft is exempt from [he 6elow Cool Roof criteria.
Note: If no CRRC-1 label is available, this compliance method cannot be used, use [he Performance Approach to show compliance, otherwise,
de box below if Exem t from the Roofin Products "Cool RooP' Re uirem
RoofSlope ProductWeight Product
ID Number� 5 2:12 > 2:12 a 516/ft2 >_ 516/kZ TypeZ
Aged Solar � Thermal
❑4
❑4
�4
❑4
❑°
The CR2C Prnduc( ID Number carr be o6/nined from !he Cool Naof Ra(ing Cm�nC�l "s HateaYroRuc� U�rec(wy ar ww�v.coolmols.om/prop�rcls/rearch nHn
Lidicale !Ne rypc of prodatl it being useAfar fhe roaf 1ap, i.e..ringle N(y raof, mphall roof, me(qf raof, erc.
ff Ilre AgeAXeJlec�ance rs na� nvnilaGle in.U�e Cool RoofRating Council's Raled Yroducl Direclory Ihen use (helnilia( ReJlecmnce v�lue fr•om Uie snme
direcmr�� ond nse Ihe eq�mlion (0.2+OJ(�1��������- 0.1f �o ob�ain n calcula�ed aged voluc. Where p is ihc Ini�ial Solnr ReJ7ecmnce.
Check 6ox if dre Aged Itefleclance is n cukuloled value uring Ihe equnlion above.
Calculae ihe Slil value L�� uring dre SHI- Workvheer ar hrrn�/Aow�r enercv cn env/lide24/ond enlerlhe resu(ling valne in �he SN! Calumn above ond atmch acopy
rhe SRh Workshee� to �he CF-I R.
� apply Liquid Rield Applied Cuulings, the coating must be applied ecross lhe entire roof surfuce nnd mee[ the dry mil lhickness or coverage
commended by (he coatings manufacmrer and meet minimum performance requirements listed in §! I S(i)4. Select the applicsble coating:
Aluminum-Pigmented Asphal� Roof Coating
Cement-Based Roof Coating
Other
Regis�ra�ion Number: Registratian Da�e/IFme: HE2SProvider:
2008 Residenrial Comp(iance Forms �
August 2009
7'rescriPfive Certiticate o1�Cumpliance:
Resitlentitd �111erntirms'
. Prujcm Namc:
nmtc
er-vz-ai
rr��:.�. ; �,i
I N uf Sturiee
flr,It$ VCi21P'1 CATI ON SUMMAR]' The enjorceuien� ngener shmild pnp special anention m�he HE/tS Meosorres spec±Jied in lhia
chec/disi Lelant A cantp/e�ed undsioned CF4It Fonn for al/ Iha meas�n�e.r speci/iedshnll br suumfl�ed io lire bui/ding inspecmr Lefore Jmal
llllcl $eelin�e S 7�BStllld HEIiS veri/icn�ion i.v reguired Jw� �hir nrenseu'e.
D YL�S ❑ NO YPS: Jn Climete Zones 2 nnd 9-16, if mm�e than 4U linear Teei of new ur replacemem ducts F�re instEdled in unconditioned
spxce, the ducts ure to b� seuled per §I52(b)IDii �nd the newly instulled ducts are m be insul�itcd pei S] 51(ij10.
❑�XCCPTIO�: Lzisting duct systems tha� are extended; which :vc cuustructed, insulxted ur sealul with as6estos.
❑ N�5 ❑ NU 1'CS: lu Climate Zones Z and 9-7G, if tLe existinE space-co�ditioni��g system (HVAC equipmeni and ducting) is replaced, Ihe
ducts ure to 6e sealed per § 152(bp Di.
❑ Y�5 ❑ NO �BS: ]u Climate Zones 2 and 9-16, if tlie existin@ H\+AC eqiupmem is replucetl (including the replacement of the nir handler,
omdoor condensing unii of a split system, cooling or heating coil, or the furnace heai exchanger} the ducis ar>_ to 6e
sealed per�152(b)lE.
❑ LXC�PTION: Uuct systems tLnt are ducumented tu have Ueen previuusly se:iled cuniirmed through HCRS
verifmntion iu accordance �vith procedures in the Reference Residential Appendiz ItA3.
'� ��� ❑�RCEI'TIU�: lluc[ svstems with less than 4U linear teet in unconditiuned sp:ice.� � .
ducl srstems uunstru
$Bt�C1eL'r3tlt Chaiee - Spllf S}�St21Tl HERS verificaiion is requireci for thi.s measwe.
❑ 1'�S ❑ NO YGS: In Climate 2ones 2 and 5-15, wl�en the existing HVAC equipment is Teplaced (including the replacement of the air
handler, outtloor condensine uni� of a sp19t system A/C or heat pump, cooling or hea[ing coil, or the fumnce heat
Central Fan Inteerated (CFI) Ventilaiion S,ysYem and Fan l�'att Dran�
The ventilation reauirements of &I50(ol do not aoolv to existine residential homes.
Ducted Split Systems - Air Conditioners and Heat Pumps: AirfloH� HcRS veri/ica�iw� is reguired.jor ihis measure.
❑ T�5 ❑ NO YES: ]n Climate Zones 10 through 15, when the existing space-condi[ioning system (HVAC equipment and ducting) is
replaced. the airflow and fan watt draw shall 6e verified ner § 152(611 Ci to meet the requirements of & 1� 1(fl7B.
Locumentation Author's Declaration Statement
I certifr thnt this Certificate of Comoliance docum
Name: �� /E ���
V
Company: �.�y„M. / /\�JF � .
\/v���nrv
Address: � , / �/r �UN�, � �.
%}
City/Staie/Zip: O�PI � �j1��7
�w
is accurflte and
Signamre:
��
4 oi i7 CEPE
P�,o„�: >if� y�'� 6���
Respunsible ]3uildiue Dusi�ner's Declaratiun Statement
• 1 am eligible under Divisimi � of the California Business ancl Professions Code tn aceept responsibility for the buildiug design identif�ed uu
this CeriiSca�e of Coinpliance. -
• 1 cenify thai the eneigy femures untl pedormance specifications for the building design identiLed on this Cenificuc of Compliance conform
w thc requirements ofTitle 24, Pnrts 1 nnd G oT [he Culitbmi�i Code of Regulatiuns.
• The building design femures ideniiGed on this CertiLcate nf Compliance are consis�em wilh lhc informmion pruvided tu ducumeni ihi:��
buildiug design on thu other xpplictible compliunce fonns, woil:sheets, calculations, plans and specifications subnduud ia thc cnfm�cement
aeenc�• fbr apnruval with this ouildin�� »ermit nnnlication.
Neme:
Companp:
Si��naturc�.
Date:
Liceiise:
Tr�r ua�.ci.ciancc or qucstiatc regording 16c Lnargr Sumdartl.t�, cnntacl !hc Lncrgp liotlinc ot: I-�1/10-772-i3//b.
l(egisirnlion Numherr Regisrr�iiun Uuie/fimc: HEIiS' !'rm�ider:
ZOOb' Ifesiden�iol Canpliunce Forma� Augua�13f1(lJ
Aop�icant to fill in all spaces except t�ose witnin heavy borOer Iines antl si9n all appravriate Oeclarations.
GTYOF COSTA MESA CONST�UC�T,IQ'[�N PE/R�MIT ' ' '"o'�' � a$ "^"' '•"' "'• '•"' """ "".
Project Address � �7�_� %GCt�OL [,.CA,K •
AppiiCant'S Mailing Addre55 TYPE OF CONSTRUCTION NEW ADD ALTERATION REPAI R
.�ti O ❑ CONVERSION ❑ DEMOLISH ❑ OTHER q,p.#
Owner's Name � � Phon� DESCRIPTION OF WORK/USE OF BLDG.
Address S Main Buildi
E
Arch/Eng. License No. TVPE OF PERMIT GRADwG FOUNDATION STRUCTV Ra� T Front
Address - �i �❑ TENANT ❑ ELECTRICAL ❑ PLUMBING ❑ MECHANICAL B Rear
Contractor's Name �1/'".���P�i!M� � phpna'�-�+�-R ��. � OTHEP A
�' � � PROJECT DESCRIPTION 5G1. Fr. oCCUPANCv C Right
Address (mailingl - � K Left
2 �� CONSTRUCTION TVPE VALUATION $ $
City LicenSe No. ZONE GRA�ING CU. VDS ACRES p R f#
LICENSED CONTRACTOf3DECLARATION
1 hereDy affirm that I am licensetl untler provislons of Cbarter 9(commencing
wi[h section ]000) ot Olvision 3 of the Bu5ine55 antl Grote55ions Code, antl
my license is in full tor e antl elfect.
LICEI152 CId55 C �
I �
Date� %�' S"9 t e 0�^•�+�
WORKERS' COMPENSATION DECLARATION
^reby affirm lhat I have a cerlifitate ot consent to seli-insure or a certificate
workers' Compensation Insurance, or a certliietl copy thereoi (Section
,00, Lab. C.
PolicY No.�� d�Zsz'9 ComPany
Certitietl copy is hereby fumishetl.
CertifieA copy �5 filed wlth the city�B�ltlinq Dlv .i/�¢-� �%�
Date %-�O'- Applicant �-`-e� f
EXEMPTION FROM WORKERS' COMPENSATION DECLARATION
(Thissection neetl not be completetl if the permit is for one huntlretl ($100) or
less)
I certify that in the p¢rfOrmance o( the work tOr which tnis perm�t is i55uetl, I
shall not employ any person in any manner so as to become subject to the
Workers' Compensatlon Laws of Calitornia.
Date $ignatu�e
NOTICE: If, after making this tleclaratlon, you shoultl become subject to the
Workers' Compensafian provislons o( the Labor Cotle, you must torthwith
comply with such p�ovisions or Ihis pevmit shall be tleemetl �evoketl.
CONSTRUCTION LENDING AGENCV
I hereby aHlrm that there is a construction lentling a9ency for the pertormance
ot the wurk for which this permit is is5uetl ($ection 309] Civ. CJ
t.entler's Name
Lentler's ACtlress
OWNER BUIL�EH DECLARATION
I hereby afiirm ihat I am ezempt from the Contractor's License Law for the
following reason (Section ]031.5 Business antl Professional Cotle: Any city or
county which requires a pe�mit [a const�uct, alter, improve, tlemolisM1 o� repair
any siructure, prior to its issuance, alzo requires the applicant for such permit
to tiie a signed statement that he/she is licensetl pursuant to the provisions o�
tbe Con[ractor's License Law (Chapter 9(commencing with Section 7000) of
��� .;,pivision 3 of the Business antl Professions Cotle) or that he/she is exempt
`.'herefrom antl the basis tor thC allegetl ex¢mption. Any violation of Section
;?031.5 by any applican[ tor a permif subjects the ap0licant to a civil
` enalty of not'more than five hundr¢tl tlollars ($500�.
� I, as owne� of the p�operty o� my employees with wa9e5 as their sole
mmpensation, will tlo the wOrk, antl the StrUctwe i5 not IntenCetl Ot offe�etl
for sale (Section 7044, Busine55 antl Prote55ional Cotle: The Gontractor'S
License Law tloes not apo�Y to an owner of a property who builtls or improves
thereon, antl who tloe5 Such wo�k himself/he�sel( or tM1rough hi5 ar her own
. emplayees, provitletl that such improvement5 are not mtentletl o� ofteretl fo�
�� sale. If, howeve�, the builtling or improvement I5 soltl witbin one year of com-
' pletioq the owner will have the burtlen of proving he/she tlitl not build or im-
prove tor the purpose of sale).
❑ I, as owner ot the property, am exclusively contratting wi[h licensetl mn-
t�actor5 f0 consttu[[ the Oroject (Section ]044, Busin¢ss antl Professions Cotle:
The ConVactor's License Law tloes not appty to an owner ot property who
builtls or improves thereon, antl who cont�acts tor such projects with a con-
tractor(s) iicense pursuant to tne Contractor's License Law). I am aware that
proof of th¢ir Wo�ker'S Compen5ation insu�ance shoultl be prOvitletl to me.
❑ I am exempt untler Section B. & P. C. tor thls reason
Date
cert
)II IS
sentatives oi t �s a
inspection p r ses.
Siqnature
Drivers' License or 5:
CMF 0865-46, rev. 10/84
_ Owner
have reatl this application antl state that the above
agree [o comply with all tlty antl county ortlinances
o builtling construction, and hereby authorize repre-
tO.en[e� Don t ab v¢ entionetl O�opeIr�ty (or
Data�-,�Tl// �
• Ing. e .
Remarks: Planning Notes:
Bar Sink
Backflow Preventer
Backflow Irrigation
Bathtu6s
Clarifiers �
Dishwasher
Drinking Fountains
Floor Orains
Floor Sinks
GasService Outlets
Kitchen Sink
Lavatories
P-Trep
Roof Drains
ReinspeMion Fee $15
Boiler
Duct - Under Ground
Duct - Ventilating
Exhaust System ❑ Multiple ❑
Firepl/Fact. Blt. ICBO #
I Heatin9 System & Ducting
0.100,000 BTU � 100,000 BT
FPa
� .� —�'___ _ I I .._._�____..
White - Builtling; Canary - Applicant; Pink - Accounting; Goldenrotl - Assessor
$15
Showers
Service Sink
Sewer Cap
Sewer Connection
Solar Collectors
Solar Piping
Solar Tank �
$wimming Pool w/Spa
Urinal
Water Closet
Water Heater
Water Service
Auto�Wash
Laundry Trays
Issue Fee
Hoodor Typel ❑
Canopy Type I I ❑
Refrigeration System
❑aioo,000sTu ❑�oo,oao
System Repair/Alteration
fire Dampers
Registers
Issue Fae
FEES
$ 3
FEES
$ 3
Automatic Washer
Construction Poie Sub.
Cooking Unit
Dishwasher �
Dryers ❑Gas ❑Electric
Fan
F.A.U. �
Fixtures
Device Boxes �
Outlets
Switches
Garbage Disposal
�@094 2/IO/B7
2one
Parking Req./Provided
ELECTRICAL
Transformer ❑ 15-50 KW
0.50+KW
Meter ❑up to 100 amps
Meter ❑over100amps
Sub Panel
Motors OO-1 HP O1'/: � 8
Inc.Solar �9-15 HP �76�15+
Microwave
Pole Light
Range
Generator �65 KW 05-15 KW
Standing Sections
Trash Compactor
� Reinspectian Fee � '$15 � � luue Fee
DEVELOPMENTSERVICESREQUIREMENTS:
2oning Approved By
Building Approved By
Applirvtion Issued By
SUMMARV OF FEES
BUILDING PERMIT $ SMIP
PLAN CHECK $ PERMIT
PLUMBING $ ISSUANCE
PLAN CHECK 25% $ ENERGY P.C.
ELECTRICAL $ GRADING
PLAN CHECK 50% $ � MICROFILM
MECHANICAL $ ' `�v v TOTAL FEE
PLAN CHECK 25% $
$
7000 TL
FEES
$ 3
Z
O
N
I
N
G
R
E
Q
M
T
S
CONSTRUCTION AND��PLANNING POOL & SPA �
APPROVALS Permit# Date Inspector qppROVALS 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, 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, O Undrgrnd., Test
9. Water Pipe-Undrgrnd. - - 60.� Backwash Lines, P-Trap, � Undrgrnd.
70. 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 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 OGas ❑Oil
23. Gas Pipe-Rough & Test 72. Underground Flush
24. Roof Freming 73. Undergrnd.StorageTank 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 PREV. FINAL .
30. Drywall Nailing HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat 79. FINAL INSPECTION �
32: Electrical Power MeterFinal 80. FOOD CERTIFICATE ISSUED
33. Final Electric Notes:
34. Fina6_Heating & Air Conditioning - � � /� �D �
oi
35. Final�Gas Pipe-Test ,
36.. Hood or CanopY �
37. Final FactorY Fireplace � . �
3S. Final Plumbing �
39. Water Service-Final , , ' -
i
40. Gas Service-Final - � ' ' '
41. Solar pomestic-Final <. � '
•42. Backflow Preventer � � � �
.43. Backflow Irrigation � �
� 44. Landscape Irrigation System . i � � ;
'45. Sound Attenuation � �
�' 46. Handicap Regulations - ; � � �
47. FINAL STRUCTURE & BUILDING ` � i� . '
i
48. Special Requirements Completed . ' , ✓� � ,
49.� Electric Release to Edison • � ,
50. Gas Release to Southern California Gas Co
I �`
51. CERTIFICATE OF OCCUPANCY �
No. Date -' � '
AGPlicanl to fill in all
GtY OE COSTA MESA � PER�y{r Nc
CONSTRUCTION PERMIT /"o��
N,..,.,.,�.
. Address
� Address�" 1
`) LICENSED CONTRACTOR DECLARA
v 1 h¢reby a��l�m thtt I am IiCOnsetl un0e�
V� menCin9 With SeCtiOn ]OOO) of Dlvis'.
Aofeszions C4tl_g, antl fnY �itense is
LicenSe No.
vovisions of
n 3 ot tn
in fu0 for
wltM1ln heavy bortler lines anC sign all appropriatc Eeelaralions.
TRACT NO. LOT NO. BLDG. NO.
9
Data��s,�z 519natur —
WORKERS' COMPENSATION DE LARAS�! N- - '-
I her¢by affi�m that I have a ce�titicdte Ot consent to Self-insure o� a
cerHfiwte of Workers' ComDensatlon Insurance,'or a�certllletl copy
GS�,..���Raf (SeCD(lo BOD 1�l�.� � _
....iN�11�r' �� omPanYT�'�Cr�
i;�";j."rrtifletl copy i5 hlrtby tumishetl. � �
� Ce�Ufletl copy is filetl witM1 the city Builtling DiviSiOn.
EXEMPTION FROM WORKERS' COMPENSATION DECLARATION
(This section naetl nol be completetl if iha.-permit I5 for one huntlretl
lE1001 or leu).
I cart((y [hat ln Iho per/o�mance-of Ihe work for wnlch tni5 permit IS'
Issuetl, I snall nOt <mplOy any pe�son in any manner so as to'become
tubjGtt f0 the Wo�ke�s'-Comp¢nsdtion taws ot Callfornia. -
Date Signature
NOTICE: If a1[er making this tle<laration, you shoultl becomo suD�ect
lo thB WOrk¢rs' COmpeniation plovi5ions Of th¢ L2bor Cotle, you mu5l
to�thwlth comply wi[h suCh p�ovisions o� this permit Shall bC tleemetl
revOk¢tl. - � - � � - � - �
CONSTRVCTION LENDING AGENCV
I hereby aftirrtl Iha['Iher¢ Is a const�uction lentling agency for [h¢ per-
fOrmdnt¢ O/ Ihe work tor which thi5 permit_is iszuetl ($eclion 3097
pv. C.).- ' _
Lentler's Name, _
Lentler's Atltlress
OWNER BUILDER �ECLARATION ` - � ' �
I her¢by,affirm inat I am fxempt from the Contractor'S LiG¢nse Law tor
tlie tollowing-rcason (Sectidn 7031.5'Business antl Profe551ons Cotle:
Any clty o[ county which requires a permi[ [o Conzt�uct, alter,
Improve, tlemolish or repair any siructure, prior to ils issuante, also re-
quirez th¢ ap�llt'vnt for such permit to file a Signetl Statement tnal he
is IiCensetl pu�5uant IO the provisions of tM1¢ ContraGtor'S LlcanSe Law
�Chapter_ 9(commencing wlth $ection ]000) of Dlvision 3 of the
•�Sin¢z5 antl PfWe55ion5 Cotl¢) or tha[ he i5 exempt thera(rOm antl the
`s tor the allegetl exempHon. Any violation of SecHon 7031.5 by
appliWn[ lo� a pe�mit subjetts tFe appllcant to a<Ivil penalty
nol more than fiv¢ huntl�etl tlo11aR (5500)_
❑ 1, as�owner of Ihe property, or my employ¢es with wages as lheir
Sol¢ compan5alion, will�tlo tne work, antl [he structure iz not IntCntletl
or offeretl for ule. (Section �044, Business antl Rolessions Cotle: Ttte
Cont�actor's LlcenSa Law tloes not apply to an owne� of a property
wh0 builtls Or imprOves lltereon, antl who tlOes such work hlTself O�
throu9h his own�employee5, provitletl thai.sucn.improvements a�e not
intentletl or oHeretl lor sale. If, howeveq the builtlin9 or Improvemenl
iz�soltl within One-yCar ot completion,.the owne� wlll have [he burtl¢n
Of proving he tlitl nol builtl or improve for ih¢ purposa of sale).
❑ I�, d5 owner oi tltC Property, aT exclusively contraGtinq' wl[h
Iicensetl contractors to consvuct the project (Sectlon 7044, Business
antl Professions Cotle: The Contractor'rL'Icense-Law tloes not applyto
an owne� ot property wno builtl5 or impwves the�eon, dntl wbo con-
t/aCts frOT SUCh' pro)ecii wi[h 'a mntractor(5) lit¢inetl pursuant to
the Conl�actor's License Law).
❑ I am ¢xempt untler Seciion � B. 6 P. C. for this
reason " —' - ' '
Oate ^ - Owner - - � -- - - - - - -
I hereby.certity that I have reatl.this appliwlion antl Std[E that.tn¢ dbOv¢
informdlion i5 correct. I agree lo comply with all tlry antl county
OrOinancesantl5[dte �elatingtoconsVuction,antlh¢reDyau[horize
representaUves of t'S <i�y to enter upon tbe above entlonetl
propert inspecti urpose5. �J 2 �
Si9nalur � • 1 DatN
TVPE OF CONSTRUCTION
❑ NEW ❑ ADD ❑ ALTERATION
�REPAIR ❑,CONVERSION ❑DEMOLISH
❑ OTHER
DESCRIPTION OF WORK
�extioc c�d�.c
TVPE OF PERMIT �
❑ GRADING ❑ FOUNDAT.�IyON ❑ STRUCTURAL
❑ TENANT ❑ ELECTRICAL.qPCUMBING ❑MECHAI
❑ OTHER '
PROJECTOESCRIPTION . - .. �. .
50. FT. „ ' - .
OCCUPANCV_CONSTRUCTIONTVPE
VALUATION ' ZONE
GRADING CU. YDS. ACRES
PLUMBING vLArvCHECK
BATHTUBS SHOWER$
TOILETS 'URINALS
LAVATORIES OOUBLELAVS '
KIT.SINKS DISHWASHERS �
SERVICESINKS � � SUMPS - � �
FLOOR SINKS FLOOR DRAINS ' ��
DRINKING FOVNTAINS
INTERCEPTORS CLARIFIERS
SWIMMING POOL � PTRAP ' ' '
WATERSERVICE ALTERATION� �
GASSERVICE � OVTlETS
WATER HEATERS � BTV�OUTPUT �
SEWERCONNECTIONS �
SOLAR TANK � - COLLECTORS - r � �
SOLAR PIPING SYS. ' �
ISSUE FEE
MECHANICAL PLAN CHECK
HEATING SYSTEM 0-100,000 BTV �
ANDOUCTING 300,000,+-BTU
REFRIGERATION 0�300,000 BTU
SVSTEM " � 100,000•+BTU �
BOIlERS BTV
SVSTEM REPAIR,NITERATION
EXHAUSTSVSTEM MVLTIPLE �
Drivers' License or 55 � ' -�SSUE FEE
,CMF O8fi5�J6 White-Builtling; Canary-ApPlicant; Pink-Accounting; Goltlenrotl-Assessor
- 3285 3/15/82
ZONING REGULATIONS
ZONE
REAR YARD (TO P/L)
PKG.SPACE REQ.
STREET WIDTH �
ZONING APPROVED BV
SPECIAL CONDITIONS:
ELECTRICAL
PLNTGp. RUEF. p�
PROPE�RTV LINE
PROVIDED
PARK FEE E
DATE
PLAN CHECK .
GENERATOR - p_j KW_ 1-30 KW _
TRHNSFORMER
'APPLIANCE ]0-SOKW_SO+KW_
MOTORS ' 0-1 HP_1-10 HP _
�(IN0.50LAR) 30-SOHP SO+Hp�_
�FIXTURES OUTCETS ' SWITCIIES
GAS TVBE SIGNS - ' " "
POLE LIGHTS - ' ' - ' ' '
PANElS ` - MAIN
SERVICE �
5.00 TL
SUB
SUB '
" "AMP
�
- APPLICATION P.PPROVED BV ' 'DATE '
{
SUMMARV OF FEES i� �
,BVILOING - "- "- ' � ' "—
�PERMIT ..y._ `_"_ n^,SMIP'"" "E' ' _' ' j
�PLAN CHECK § ' PERMIT ' • ,
ISSUANCE $
�PLVMBING S� � � GRADING S
.PLANCHECK § - � .
ELECTRICAL y � b
�PLANCHECK E - �MICROFILMIE
MECHANICAL E - TOTAL FEE E ,
-�PLAN CHECK § LE55 H�- ' -
_VANCEPC S_
. FINALFEE § ��
CONSTRUCTION AND PLANNIjJG POOL & SPA � � •' �• '
APPROVALS Permit #�J Date Inspector qppROVALS Permit # - Date _ Inspector
1. Temporary Electrical Service or Pole 43. Pool & Equipment L'ocation � • -- -- - � -
2. Soil ipe-Undrgm • 44. Steel Reinforcement ' - • ' ' ' '
3. Electrical Conduit Utility-Undrgrn 45. Forms '
4. Electrical Conduit-Undrgrn 46. Electrical Bonding
. tee ein orce 47. Rough Plumbin & Pressure Test ' '
6. Electrical UFER Grn 48. APPROVAL TO COVER-GUNITE . � ' � '
7. Footings - ' 49. Electrical Conduit-Undr rn ' � �
8. Foundation �� 50. Gas Pipe, ❑ Undr rn, Test � � � �
9. .Water Pipe-Undrgm 51. Backwash Lines P-Tra ❑ ndr 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 ElectricConduit ` ' i - �56. - Electrical-Final � �
15. Rough Electric-Wiring - ' ' - � ' 57. Solar SYstem-Final '� ' '
16. Rough Heating & Air Conditioning - • encing & Access Approval
. 77. Ducts in Structure ' APPROVED FOR PLASTERING
18. Ducts, Ventilating . .
79. Gas Pipe-Rough & Tesi - 60. POOUSPA SYSTEMS FINAL
20. Roof Framing. ' � � '
21. Roof Sheathin � � ' � � -� . . ,
22.. Frame and Flashin NOTES: •
� 23. Insulation '" �
24. Lathing & Siding � ' �
25. Drywall Nailing �
. 26. Plaster Brown Coat -
27. Electrical Power Meier-Final � � ' '
28. Final Electric � �
29. Final Heating &.Air Conditioning � � � '
30. Final Gas Rpe-Test 8' _ ' ' '
. 31. Final Plumbing . ' -'
32. Water Service-Final ' �
33. Gas Service-Final � � ' �
34. Solar pomesticFinal " � ' ' � �
35. Landsca e S rinklin S stem ' ' � ' "
36. Sound Attenuation � �
. 37. Handicap Regulations � - ��
- 38. FINAL STRUCTURE & BUILDING ' � ' � ��
39. Special Requirements Completed ' '
40. Electric Release to Edison � " -" �
. 41. Gas Release to Southern Califomia Gas Co. -/ � � �
42. CERTIFICATE OF OCCUPANCY
No Date .
-� 12266
COSTA MESA BUILDING.SAFETY DEPARTMENT
P. O. BOX 917 COHTA MEBA. CALIFORNIA
For Applieanf +o Fill In Complefely
'YYPE ORy PRINT
BUILDING ___. _4� � �_____._
GOSTA MESA. CALIFORNIA
ADDRE65.SU 9 1 3800 E. Coaet Ai hwa
���, Corona del Mar NEo Or 34220
OARCHITECT � nd Lavanas NEp'�i 3JOlO
FEE RECEIVED
��NANCE DEPT.
APPLICATION FORYP�tMjTOSTA MESA
Loc 3o BUILDING
Plan �l R 2A �
For Office Use Only
nece�rr rvo.
RHCENED OY �ATB XeC5�VE0 OATE IBBU O
l —�� e�
aoo ess 2824 Columbo Avenue
COSTA MESA. CALIFORNIA
R ENGINEER
aooREss 3432 Vi& orto� Newpott Beach FIRE
ZONE
__..__.____ Menrn f:mm�ratinn � APPROVED
c�rr Coiona de1 Mai
��cTNo. 98808 NO. � 3��20
��ZE „r �n Y ok � u°W°��a�o.. �
SEiBACK LIN2 FRON���1 ��f
CENTER OP 8THe6T Yv REAR YARD L
SIDE VARD ILEFT S IRIGHT S
I DESCRIPTION OF WORK
BUILDING NO. OF 1
SIZE SS v SO ROOMS B STORIES 1
ZONING
IONH 1/�� I NO. OF I UBE OF NEW
�� PLANB BOILDING
�e,,,�Lot 30 Tract � 3749
D /
o/
EVES
Conatruct Si il Residenca
with attached garage
i NERE9Y AGI(NOWLEDOE TXAT I AV2 pBAD TXI9 APPLIGT N THQ AMOUM eHOWN UNDEH VALU�TION IB FOR THE
AND 9TAT¢ TNAT TXE F60VH IB RflECT AND AGiiEC M M� pUPP098 OR EBTABIIeNIN6 A PERMIT FEE ONLx.
PLY WITX ALL CIiY OImINANCE AND T8 UWB R6011 NO
BUILDINo CONBTRUGTON. VALUATION
SIGNATURE OP y� PERMIT FEE $ 3Z.00
PERMITfE
g 13�SLS.00 pLAN GHECK g 16•OO
AUTHORIZE�AGENT �ojact Manager 48.00
TOTAL FEE
C
O
LL