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Home My WebLink About521 CENTER ST - Building PermitsOwNER CITY OF COSTA MESA DATE 6-z5-81 JOB ADDRESS S�1 f.antar Ctl'PPt BUILDING PERMIT =x src... _ - r v � . fi� . CTIONS $OIL cns W�TEA ROOGH PWMBING PROP. SWR. LINE �_ � HOUSE CON. � SPRINKLIN6 SVSTEM MISCELLANEOUS ROUGH HEATING �ND AIR CONDITIONING TEMPORnRY SERVICE OR POLE UNOERGROUND � POWER � ROUGN WIRING TRENCHES (J FORMS STEEL REINF FLOOR SYSTEM BONO BEnM �, STEEL REINFORCE � SMERiHING FRnME /.NO F�RSHING LATHING — IN r� OUT � P�15TER. BROWN CORT CTURA�, FINRL . .ING, VENT., REFFIG. AND A.C.. FINA� SUBCONTRACTOR ER �L�L•' ROUGH MISCELLANEOUS ROUGH HEFTING CONDITIONING POLE ROUGH WIRING TRENCHES � FORMS STEEL REINF. F�OOF SYSTEM BONO BEAM STEEL REINFORCE SHEATNING FRAME AND FLASMING �`- �,0 LATNING - IN OUT P�ASTER, BROWN COAT TURAI.. FINRL h NG, VENT., REFRIG. AND A.C., FINAL PLUMBING, FINAL ANO GAS TEST ELECTRIC, FINAL BUILDING, FINAL d- DATE 1-19-71 VALUE S 1 SUBCONTRACTOR Bailding Department ��2�PPLICATION FOR PERMIT P.O.BaF'3!7 : • t'� gUILD1NG � ' C85TA MESA; CALIFORNIA FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY Building f Receipt No. Permit N Address 7/ G Q1� 7�Q /Z � < Costa, Mesa., Cia�01'll18 cerve by Date Rec'd� � Datn Issu Nearest �� —/�� /� Cross&t, i� p✓Z ��j �n Lp 6ui�ding y Address oL •� �•C�.(, �C� Owner �,� y3 , S i ni s- Costa Mesa, California Mail Address //O G ily ! S C v/✓S i �/ Nearest �-� Tel. Cross St. Gty !/' h 11/� C/il A No.� Y h� 9} �4 Zone , n I No. of I Tvpe��f Group, Size of Lot 3 v fl 4se of Existing Bldg. �cf 6� Setback Line fromr Center of Street L � DESCRI New I I Repafr I I e�ua��9b , Size Y � wbr Wa :ring � c �se oT New _ _ I hereby acA and state th with all Ci1 building rnn Signature of Permittee _ Valuatlon �CS �� . $ — , m zoa io�ss o. r. e. �.r•a ) %��— D ��—/o No. of Bldga c n New on Lo� 3 I�.S•liFi1 r that I have read this Applicatibfi �e is correct and agree to comply Lath. Int. ices and State Iaws regulating Lath. Ext ��.�� . Plaster.InL Permit Fea $ Plan Check $ Total � _ Cc�STa MESA APPROVALS ion � Inspector �� Date Masonry Reinforeed Bond Beam s� • � .�e .. � � :. . . i . . '1 . rLll1 iL[>1\ �i Show locatlon and distancea from � property Iine and betwetn buiidinps H ON : cn C � %� O u N � ♦ � 1 � n , , , �2�'�7 JAN 19-7lcnsa�0 572 0+�****5.00 � COSTA MESq BUILDING-SAFETY DEPARTMENT � P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 - APPLICATION FOR BUILDING PERMIT For Applican[ io Fill in Completely RECEIVE�j' DATERECEIVED pq�BS�D� ADDRESS S� � l„ �� 7E,` S� V� � � � � J V PERMf�T�`1 OWNER O j — A.P. NO. �O — �i-/4A MAIL ./ BVILDING Z . ADDRESS ��I -j�J S ( ADDRESS .Sa dU CITV 0 No`.�6ys3Y TRACT LOT BLOCK z Z Q CONSTRUCTION . W AD A P O N LENDER am J � BRANCH `�A C J N OWNER l l /�NLEi¢R�/ J a Oli ENGINEEF NEL �/S�/� S VALUg /L v^ ✓'� J V Q FIRE W¢ ADORE55 20NE TVPE GROUP W Z CONTRACTOR OW N L- BVPROVE� DAT 7�. GL %) E/ � �� J Q m Z S 1 c�Nr�� sr J � ADOFESS w w TEL. Z�NE NO.OF /� USE OF NEW �= CITV E NO. � � P�� v� BUILDING Z F- w � STATE CITV VAFIDS APPqOVED VARDS APPROVEO y p� LI4 NO. � LIC. NO. MAIN BUILDING ACCE$$ORY gVILDING 7� SI2E � /� n NO.OF BLDGS. (FROM GLSTREET) OF LOT 11 C,l � NOW ON LOT � FROM' FT FT, USE OF EXISTING BLDG. I FT. H S12E OF NO. OF Z NEW BLDG. ROOMS STORIES L. SIDE F. FT. U EMERIOR WALL ROOF COVERING COVERING REAR FT. FT. USE OF BUILDING AN� WORK TO BE PERFOFiMED DISTANCE BET. BET. MAIN & �N N MAIN B�DGS. ACCESS. BLDGS. c� VAR.#` � DATE O (�.j N LN C.U.P.# APPROVED (n — O(J C7 F �/ APPROVED � p � V , w z � VI hereby acknowletl8e that I have reatl this ap0�ication antl state � thut Na ebove information is corract antl e0ree to comply wit� � all laws ragulating builtling consttuccion, antl I shall not employ F any parson in viola[ion ot ihe workman's compensation laws of y the Stete oi Celitbmia. m � zI hereby certity [hat I am properly licensetl as a contractor under SQ. FT. o ihe State of Califprnia Business antl Professions Cotle, Divisicn 3, THE AMOUNT SHOWN UNDEF VALUATION IS FOR � Chaptar 9, antl that such licenses ere In full torce antl eftact, or I THE PURP06E OF ESTABLISHING A PERMIT FEE ONLY: m am ezempi from �he provisions ot the Stote of Celitornia Business ¢ VALV TION �� m entl ProtassiDns Cpde, Division 3, Chaptor 9. PERMIT FEE $� � ryryryjjj N � SiBnat�re of m Perm(ttae /� � $/�Di PLAN CHECK $ E S __ `o Authorizatl ant LL TOTAI FEE 5 � • COSTA MESA BUILDING-SAFETY DEPARTMENT � P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 For Applicant to Fill in Completely — Use Ink Only � BUIIDING �� A�r� �� _ ADDRE 5 � O /. Q �a.C' /�� d ciT� �s�' �1E6.� OONSTRUCTION /p LENOER [�/�� BRANCM ADDRESS ARCHITECT OR ENGINEER �� ""'_.. �� L. .�/G APPLICATION FOR STRUCTURAL PERMIT RECEIVED V PERMIT 7179 „�C5 B 50 TI. A.P. NO. �(-- �Z�— BUILDING ADDRE55 VNIT OR SPACE NO. TR.NO. ,� LOT�� N�LTER REPAIR MOV APPROVED DATE E DEMOLISH GITV � N�� "�� jf F STATE CITY APPROVEDSETBACKS LIC. NO.�z 'l � LIC. NO. � SI2E NO.OFBLDGS. (FROMC/LSTREET) L OF LOT NOW ON l0T � RONT FT. a VSE OF '� EXISfING BLDG. y � Separate permits are required for L. SIDE FT. Q electric, plumbing and heating work: AEAR FT. [.W.� USE OF BUILOING AND WORK TO BE PERFORMED PLqNNING ACTION a c �// `JQ !�(I � �.ryIG. APPROVED � � APPROVE6..� � / �p U P 7 .d a w 0 I heraby aeknowled8a thet I �eve rea0 this applieetion and state °�` q� that t�e ebova InformeNon is correc< and apree to comply with d all Iews regulatinp �uildinp conRruction, antl I shall not employ � � eny person In violation of the workman'z compensetion laws of m the State of Californla. m 3 1 hereby eartity that I am properly IlcenseC es e eontractor untler SQ. FT. N Ue Stata of Calitornia Businau end Protessions Cotle, Division 3, THE AMOVNT SHOWN UNDER VALUATION I FOR m Chaptar 9, antl that such licenses ere In tull foree antl etfect, or I THE PURPO6E OF ESTABLISHING A PERMIT FEE LY: � antl Pro esslonam th�e provl�aioo�n3of tha� of aliforni Msiness VALUATION PERMIT FEE 3 �� / �i,� ✓ PLAN CHECK y �'�`) / Sipneiure of � ��r—•r Pe�mlttee / $ �D� TAX S LL or !�—`�' � � r � �� Aut�orizetl pent Date TOTALPAID E .EA-4�1 � AGo�lcant lo �� all spaces wllhin heavy bortler Ilnes anE sign all apo�ooriata tleelarations. CITY OF COSTA MESA P M�T NO t� TRACT NO. LOT NO. BLDG. NO. CONSTRUCTION PERMIT oZ 6 ' ' + ' Project Address —2 � G+ � t� TYPE OF CONSTRUCTION OWne! o Phone ❑ NEW --❑ ADD ❑ ALTERATION AddfCss - - - ❑ REPAIR ❑ CONVERSION�DEMOLISH . Alch�Eng.- . �lcense No3, 7/ ' � OTHER DESGRIPTION OF WORK Address- - � - - - . . _ ' Contractor � Phone6 '�7p ,TYPE'OF PERMIT - - 'Atldr65 /J Z / - ❑ GRADING -- ❑ FOUNDATION ❑ STRVCTVRA� LICENSED CONTRACTOR DECLARATION � _� 7ENANT O ELECT.RICAL' �F'LVMBING ❑MECH I hGrlby aHi�m lhut I am Ilcensatl unEer p�ovl51on5 ot Charte� 9(Com-� � y man<Ing �wilh-section.7000) of Dlvlzion 3. ot the Bu5ine5s antl ' D OTHER ' '�' ' Ao(eszions Cotle, antl my Ilcense is in }WI force antl .eftect PROJECTDESCRIPTION ' 'ucense CISss " � - " - LJce e No.� 624� �f - - ' • � - � ,- -- 'Date /'i. C --I�Lcl9nature [$�.�iCf� ' _ - 54. FT: _ .. . . _ "" ' ' WORKERS'COMPENSATION ARHTION '� OCCUPANGY_CON57RUCTIONTVPE I ne�eb aHirm thdt I hdvC a certHlcate of co�sent to self-insure or a �� cerHfifate of Workars' Compensatlon Insurad�e.�ar a certtl7e0 copy. ��VAWATION� ��20NE therco/ (Sotllon 3800, Lab. C.). � . GRADINGCU. VDS. ACRES Polity NO. - CompanY - � 7 Certitletl topy Is hCreby turNShaq. REMARKS: ' ' ' . 1291 I/27/B2 9 A.P. � . ZONE ' ' PWTGp. gRUEF�. p•¢ , SETBAC PROPE�RTVNLINE SIO VARD -. _ . LE ANIC 5ID E V . RIGHT - ' ' REAR'YARD (TO P/L) "" " -' - ' ' - PKG. SPACE REQ. ' ' ' PROVIDEO-• -� � .-STREET WIDTH -"" PARK FEE b - 20NINGAPPROVEDBV • -� DATE ' SPECIAL GONDITIONS: ' ' " � CertlflG� COpy I5 fllatl wlth thB Uty Bulltling DlviSiOn. . . EXEMVTION FROM WORKERS' COMPENSATION DECLARATION � � This settion neetl not be completetl if the permlt I5 for one huntlretl �ES00) or less). " ' " " " . . '" ' � ' ' - ' certify [hat in tne pertOrmance of the work tor whiGh [his p¢rmit I5� Issuetl, 1 shall not emPloy any person In anyTanner'so as'lo become PLUM6ING ,- ' �PLAN�CHECK - sub7ept to lhe Workers Compeniation Laws of Ca�lfornla.�' ' �Dd[G � Si9naturE - B/�.THTUBS ' '$HOWER$ ' - 'NOTICE: It aftar riiaking [N5 tleclaratlon, you shoultl become subjecl •TOILETS .- URINALS - ^ r to the Workers' Compensatlon provislons ot the Labor Cotle, you must �- � forthwith comply wilh suc� provlilons or lnls Oermit snall be aeemetl LAVATORIES DOVBIE LAVS - � revoke0. � ' - � -� KIT.SINKS - - •DISHWASHERS �CONSTRUCTION LENDING AGENCV I hGrlCy al(IrT tha[ [hera IS e con5trutllOn lentling agency for th¢ per� SERVICE SINIC$ SUMPS • - --- formance oi tne work for w�ich this permit is issuetl (Section 3097 C1°'"C'�' "" - ' " - " - ' - " - FLOOR SINKS ' ' FLOO RAINS ' - Lentler's Nama � "-- � ' '- " '- - ' ' -' ' - 'ORINKING NTAINS � - - - �Lentler's AtlOress ' ' ' OWNER BUILDER DECLARATION� - ' WTERCEPT LAFEIFIERS "-' - ? "�' - I here�y aflirm that I amexempt from tne ConVactor's License Law (or the-following roason �(Soctlon 7031.5 Buslnoss-antl.Pro(essions Cotle: SWIMMING P -PTRA - - �- - � � Any city or counly w�ich requires a perrql[ to ConS[rutt, altGr, t It 1 1 .50 Tl T ti._..... _. . . .'' . .. . . .. ._ � ' ' ' n, .•,'..� _ � �ELECTRICAL - • -v�AN CHECK � - S"DWGLLTI ' _ . _'_ GENERHTOR Od'KW_1-10'KW - - - 'TRANSFORMER . . iAPPLIANCE -- 10•SO�KW_50 t KW � _MOTORS � - 0-1 HP_1-30 HP - - (INC.,SOLAR) 30-50 HP 50 t HP � FIXTURES OUTLETS SWITCHES- � �GAS TUBE SIGNS - - - . - . . _ _ _ POLE-LIGHTS - -- � 'POCES " ' METERED' "'SUB - " i I� ImOrOve, tl<molish orrCpair any strutture, prio� O� 5 SSuanca, a so ra- yyqTER SERV ACT ION - • PArvELS MAIN SUB � � qUi�es 1�e ap.li�ant io� such Datmft Lo tile a sI9�e6 statem¢nt thai h0 is-Ilcensea pursuant to lne pwvislons oi tne COn[ractorY Llcense.law � GASSERVI 5 ' ' - �SERVICE - - �• -AMP - - - - ,�Chapler 9(commnncing with Settion ]000) of Dlvision 3 01 tne Buiiness antl Prdesslons CODO) Or lhat bo is azampt therefrom antl lhe � yyqTER M TERS U TPUT � - - �� - -- ' basis tor the allagetl oxemptlon. Any violation of Sectian 7031.5 �y ' �S�'-�� appll�nl �or a p¢rmit-subjeCts��he appl�Gant �to d Civil penalty- SEWER�CONNECTIONS � ^ - � �- - - . � ._ .- - _ . _ �'--=iot more than live huntlretl tlollars (E500). l.'.; `I, a5 Own¢r of"lhe property, or my employeez with wages as th¢ir SOLAR TANK COLLECTORS^ � � - ---- .. . ._. ._ _- sole compensation, wlll tlo the work, antl the structure is not Intentletl dr afteretl"ror sale. (SecUon ]044, Business an0 A'ofe551on5 Cotle: The SOLAR PIPING SVS. • - ' ' ' �SSUE FEE - '-- � - �Contracior's Llcense Law tloes not apply [o an owner ot a property i wtio builEs or Improves thereon, and who tlots sucb wo�k nlmself or ISSUE FEE '- ' -' -:�PP��CATION APPROVED BY - �- '. DATE - ' IhrougM1 hi5 Own Cmployees, provltlCtl that SUCP improvementt a�e not ' ' Intentledor offeretl tor sale. I/, howevor, the bulltlln9 or Improvement -ry�ECHANICAL - PLAN CHEbK � � �SUMMARV OF F ES � � is soltl within ona yoar ol compintion, tne owncr will bava the burden � o( provin9 �a tlitl'not bu11E or improve ro!'�he purpose'of sale). HEATINGSVSTEM O�100,0008TU - BUILDING ' EF�E 4JA/ ✓Fr�� ' I JQ .�.I,..as ownar_ 01 tba properly, am. excluS��ely contracling w��h qND DUCTING PERMIT 5 �� , E Ilcensetl contraclors to conilrutt the pro7oct (�<tlon ]044, Business 100,000 + BTU � pLAN CHECK E , PERMIT 1 antl Prot¢ssions Cotla: -The Conlraclor'S Ucon50 Law �O¢s no[ appry.l4 . . . ISSUANCE S an owner of property wna builtls or improves thereon, antl wno con� REFRIGERATION�� 0�100,000 BTU , PLUMBING E � - . tracls hom. such_prolects witn a_contractor�s).��esnetl pursuant to, SVSTEM . . _ GRADING � E ' the Contractor's U<ense Law). 100,000 + BTV - - � PLAN CHECK �S - - - ' .0-lamexempt-untlerSecHon - 'B.6P.�C.torthis BOILERS BTU � ' ELECTRICAC'-E - E - �reawn - - -- pLANCHECK § ' � � MICROFILM E � SVSTEM REPAIR,ALTERATION - Dale Owner ' '� TOTAL FEE S I herebyterlitythal I have roatl l�is appliWtion antl 5lale lha[ the a�ove EXHAUST SVSTEM MVLTIPLE � MECHANICAL•_5 - LE55 AD- informatlon Is torrett. I' agree to comply with all tlty anU county PLANCHECK E �VANCEPC S_ ortllnanC¢s anA stata laws r Ing t0 COnsl�uctlon, and hUeby au[horine . rapresentativos' f tM1is� to enter upon'the'a0ove mentionetl - ', � property tor S ectlon u� o s � Sv Signature Date �`19 � FINAL FEE b Drivers' i nse or $S �_� <� �SSUE FEE . _ . CMF 0 5-46 White-Builtling; Canary-Applicanq Pink-Attountin9: Goltlenrotl-Asseisor , . � � � , CONSTRUCTION AND PLANNING � � ' • POOL & SPA ' �� , �, � � � APPROVALS Permit#�� Date �Irispector pppROVALS :�, Permit# � - Date Inspector � 1. 7emporary Electrical Service or Pole 43. Pooi & Equipment L'ocation '' '- - •- -� -. 2.. Soi .ipe-Undrgm, � ' 44. Steel Reinforcement � " ' " ' � ' - 3: - Electrical Conduit Utility-Undrgrn _ .. __ _ _ . 45. • FormS � ' - � ' �- -� - - 4.- Electrical Conduit-Undrgrn.. . . _ _ . . . . 46. Electrical Bondin ` - - - - � - - - - - - � - 9- _ ._ tee , ein orce � 47.. Rough Plumbin & Pressure Test ' � -� •- - � - - - 6. _Electrical_UFERGrn__ __ _ _�f 48. APPROVALTOCOVER-GUNITE - - - 7.. ootings_ 49. Electrical Conduit-Undr m � � ' -8. �Foundation _. - - -_ - ' 50. , Gas Pipe, � Undr rn, Test - 9: -Water Pipe-Undrgm . - � - " _ 51 . .Backwash.Lines P-Tra ❑ nd� rn ' ' - ' - ' � 10. Structural� Floor Sysiem • .. 52. � APPROUAC TO DECK �' �-" " ' ; -il. -Proper�ty-Sewer_Line.& House Connection � - - --- - - 53'. -�Backwash &�Rece tor-Einal � - -12. - Street Sewer Connection ' � - � - � - - - 54. �Heater& Vent-Final � - -_ -'. 13. _ .Rough..Plumbing � ` -- ---.- ` - . .. - . � - ; 14. Rough ElectricConduit - ' � " " -56. Electrical-Final-� - - ' ' - � ' - 15. Rough ElecVic-Wring i - - � 57. SolarSystem-Final - � • ' . 16. - Rough Heating & Air Conditioning � - " - � - - • � encing & Access Approval . �17. Ducts in Structure � � - - � - - _APPROVED.FOR.PLASTERING' � 18. Ducts. Ventilating - - • . -. . -. - - -- _ - - - - --- - --- - . � . .- - 19. Gas Pipe-Rough & Test ' �� - - .60.- POOUSPA SYSTEMS PINAL , ' ' ' ' � � ' , � '- � . 20. --Roof�Framing -- - -- - - - - � � � � ' ' � ' 21. Roof Sheathin NOTES: ' - ' ' 22. Frame and Flashirt � - - � � ' ' ' • ' 23. Insulation � � � - - �- - - - � - � - - - 24. Lathing & Siding- � - - � - - � - � - " � � � - - 25. Drywall Nailin9 � - - - { - � '- - -- � - - 26.� Plaster BrowmCoat - -� - - - ' � • 27. Electricai Power MeterFinal � - - - - - � � ' � � � ' � 28. Final Electric - - • - � • - - � 29. Final Heating & Air Conditioning - - - - - � - ' � 30.- Final Gas Rpe-Test � � - � -�= - - 3i. Finat Piumbing � � � 32. Water Service-Pinal -- � � - - • - - � � ' � �� -33. ��GasService-Final - � - � � 34. Solar pomestir,Final � ' ' � ' - • � � � • 35.�'landsca eS rinklin �S stem'" ' ' ''� ' � � � � 36. Sound Attenuation " ' � � � � 37. Handicap Regulations " � � � ' � ' ' � ' 38. FINALSTRUCTURE&BUILDING ' ' % $3 � � � 39. Special Requirements Cortipleted - ' � � 40. Electric Release to Edison •� � 41. Gas Release to Southern California Gas Co. � � � �� - , 42. , CERTIFICATE OF OCCUPANCY - � - - No.__ Date � BUILDING PERMIT NO. E""""' m TraGt B�ock LOi �y— Plrmit No. C Builtlin9 � ^ � . 7/ _ viumoin5 G AOE�lSS a VU �rmi: No. � D Crosi � MecnaNcal C Area SVeet �'ermlt No. C R QN.p�� /�/ 1/ 7 Gl � j TYDe 01 PrOject: ❑ New ❑ Altm ❑ AEOibon � / � V � � � HtltlreSf �� 11 �J �j �� T ❑�EeDair ❑ CO�ver� ❑ Demo ❑ O<CUDanGy PmL I v i ��Y :��%i e2 ..5�3� ��e,r,, � P�o�< A.P. SuD. Dist✓ � 4 Inso. Area � A�cnite<V y I DGsiqne� l�Cenie NO. Z�^B SD�. �mt. NO. AOtlr<si SetbdGkt P/L Front UL St. $Veet wmtn Varas Lell ign; ear City ZID �one ave ro�. e i9 . . Enqineer Licenie No. � arkinq Spates equirOC ov� e overe R Atltlres5 m CItY Zi0 Pnone p,e 9nt S�o�es Fam ly " � L�CENSED CONTRACTOR'S DECLARATION vara Fees � ves Fee � Reduiretl NO C.T. ReceiD: � I h�rWy aftirm tnat I em lieensetl untle. provisions ot Cheo�e� 9 L Icommencing wix� S�ction 7000 of Divisio� ] o� tM B�siness and Zoninq AooroveC By: O+te Professions Coae ana my licensa is in full lo.ce antl a��d. ?� License Clas• �� licensa Number I > OaieG%F'�S'/ Contracto.7/U�//�t.4/G� !S'F�l i.c/G �n�sc. E a,ce..ss C' /11.c�4�m A/ a000:ea use LL CiryanoZio�Ay f/M �lJ, pna� f%� o/5vucture � CONSTRUCTION LENDING AGENCV I � I nereby aHirm that t�ere is a connr�ction bnCing agency fo� [M1e I + perio�man<e of ihe wo�4 tor wbic� t�is oe�mi: is iss�ea (Sec. 3097, Oct. Type CoOe ' Civ. C.1. Cidss ConSL Vear ' y �enae�'s rvame USE/OCCUPANCY SIZE 5�. FT. i E �antlar's Adaress � J OWNEA-BUILDER DECLARATION � I � I herooy affirm tnat I am �n�mpt lrom xh� Convacto�'s Licensa Law � � � far t�e lollowing raesOn: � C❑ I, ps owner of ifle propmiy, O� mY �mDIOV��s wiUf wapes es [heir 2. wle cOmpenution, will tlo t�e work, entl t�� t�ucture is not I � iManaea or oHned fo� saie. ❑ I, as owner of tne proDe/ly, em ezclufiv�ly conVscLinp witn 3' � � IicQnsetl con[�aciors io connruci ih1 p�Oject. „d, ] I em aiampt unOo Sac , BdPC �0� tnit raason 4' W a Det• Owner . E WOHKERS' COMPENSATION DECIARATION To[al Valuation I Si na.aby eflirm thai I �ava a uriificeie o1 confm� w w�-insu.e, Encroacnment Permit Reoui.etl ❑ Ves L� r+o � 0� e tenifi�aie ot Wor4�ri COmpansetion Inwrento, or e carpi}ietl � C <ePV tha�e01. G�aEing PmL Gratlm9 t�i Policy Noyz 9/�O�'1rCompany / �� AaoWrea ❑ Ves ❑ No Pmt. No. ' 6 Wu ar::'iaC w?v b 1+a.oGy furnisnstl. �/�� RDu9� GraGinq S a CertiliW coOY �s 1iIW witn O� ,,Cou�R E / R Q � / AODrovetl by: Date Dara� �^S/ Aooi�canj/ h 3 CERTIFICATE d EXEM ION � FROM WORKERS'COMVENSATIONINSURA E Z (Thi� wction n��tl not be como4�atl i1 O��mit is for 5100 or lassl. � I catitv tn�t in tM pa�formenc� ot N� work for wni<n tnis oarmit is 3 itfultl, I sl�ell nOi �mO�Oy eny Oaripn iI1 �ny minnl� s0 �i t0 b1Com0 r suCj�ci i0 �� Wo�koi Compmsatim L.w. o� C�i��a.�u. PEPMIT FEES Datw AOOlicant I NOTICE TO AGPLICANT: II, efUr m�kinp t�it Cmtific��• 01 SVuttunl S Plan C�ec4 3 I Er�moiion, yo� �no�la b�com� au0jac[ to th� Wo.t�ri ComDanution P�ovi�iom ot tM LeDo� Caae, you mvn 1on�wiU+ cOm01y wiin tuc� Soecwl ElecViol f Inves:. s � O�OvisiOnf O� t�it DHmil a�sll ba tlnm�tl ravokeC. � � CERTIFY TIVAT I H4VE RE�+D TMIS APV�ICATION AND $TATE p��mbing 3 I THAT THE ABOVE INFORMATION IS CORRECT. i AGREE TO COMPLV WITM AlL COVNTY ORD�N4NCE5 AND STATE LAWS I f7ELATING TO BUILDING CONSTRVCTION, AND MEREBV AUTH� Mac�anical S I ORIZE REPRESENTATIVES OF TMIS COUNTY TO ENTER UFON � THE ABOVE MENTIONE PROPERTY FOR INSPECTION PUR- pfe-GraEe I P�%�i. �/,!/ � �/ � ,+ / ,,, ti� Inspectlon s I %L{O{�% �w•!� a _f '��' �� ArGraae Permi� �Sipnet�r• Applica i or Ap�nt Os�a qec. No. s Issue f ,��:-,�.��F,� ,� rd��.� � I Print AOO��unYs/Apeni'a Name All speces within this boz must b� rompl�t�d to promss P�'� Issuance i Cf1lCk BY� APP�ovetl: � CMh WSSiO �tlU-Ltl) �lV.O/tlU