HomeMy WebLinkAbout356 15TH ST - Building PermitsAPR 1 8 1960
GENERAL CONTRACTOR Armitage Bldrs. VALUE $ 101.00 , _
A^ N0.117-261-0 LOT TRACT FIRE ZONE DESCRIPTION OF WORKRe–lOC3te Gar.
I. ECTIONS
DATE
GROUP ,T TYPE IT ZONE R J,
Underground Soil U.G. Water
SUBCONTRACTOR
PERMITS
ISSUED
Underground Gas
—
DATE
NUMBER
Overhead Water and Gas
Rough Heating
Rough Plumbing
Miscellaneous
Prop. Swr. Line House Con. St. Swr,
Sprinkling System
Heating, Final
Plumbing Fixtures
Final Gas Test
Construction Pole
Underground Power
Rough Wiring
Trenches ASI Forms �jl'I teel
(o t_
•
Floor System
Steel Reinforce Chimney Re -Rod
Bond Beam
S>>""fishing
F'.,ifY,ie and Flashing
_
Lathing, In Out
Plaster, brown coat
Plumbing Fixtures, Final C_
Electric Fixtures, Final
Building, Final
_
OCCUPANCY
Form 210-3M-4-59 _ 1 Uq6•
(714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.(8bq WING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626
Job Address:
356 16TH PL
Suite:
Vicinity:
THROUGH OUT HOUSE
Primary Occ:
R3
Parcel Number:
42519219
Applicant: KAYLOR,GLENN
Address: P O BOX 11723
COSTA MESA, CA
Owner: KAYLOR
Address P O BOX 1
r Z�P';.I
REVISED 07/06107: ADD STUCCi
CHANGE OUT 10 WIN OWS (Th
� FRENCH DOOR;'NO CHANGE It,
i Plan Check:, � $0.00
Permit: $97.25
SMIP-Re`s`.' �, $0.50
SMIP Com:AV,� $0.00
�Q—Other:, A\ rl ` $0.00
!nspection:� ���� $0.00
Total\��$97.75
Type of Construction: V -N
Zoning:
Phone: 949-212-5721
Zip: -_92627
�n Fgg
L_ LjhZ_ _p'1'92`627//
Phone:
License: 000000
Phone: ! t
�l
icense:(�\,
'n-�- ` SCOP
ERIOR OF DUPLEX
Eng:
Address:
ae I W
3H.OUT DUPLEX) LIKE FOR LIKE, AND CONVERT 2 WI
ODER FOR DUPLEX. WINDOWS SHALL MEET 1997 UBC
l[ Zr FEE SUMMARY
Status: ISSUED
Applied: 05/30/2006
Issued: 05/302006
ISSUED �QA
•, Phone:
License:.
DWS INTO 1 SLIDING GLASS DOOR AND'4
RESS REOIREMENTS', -- �
Bic Valuation: --a4;900;00�
IaimValuation: l��9� $4000.00;
i
� �� r rm�:rvirvrvm� awrvm� ! Ci �
SETBACKS r ��
MAIN STRUCTURE Front O' 0 \-'��'�Rear 0 0 I �Le@ 0- 0 �A_—�y� � Right G 0- 0
ACCESSORY'\ Front �D%0\\R\ \ 0 0 Left 0 0 , jght� 0-.0//)
st
PARKING \�\� � � Re' u ri a 01\�
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: This permit shall automatically expire and become vold 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) 7545626
YLG Cr:rl:•i�!P
DECLARATIONS
WORKERS' COMPENSATION DECLARATION: v -
I hereby affirm under penalty of 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 tabor Code, for the performance of the
work for which this permit is issued.
❑ 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: Policy Number:
(This section need not he completed if the permit is valued atone hundred dollars ($100) or less.)
PkI 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' compensatlon provisions of Section 3700 of the Labor Code, I shall forthwith
comply with these p I -'1 ,C
Applicant Signature: 72 Date: y - V - 6
WARNING: FAILURE TO SEC E WORKERS' ODMPENSATION COVERAGE IS UNLAW FLA. AND $HALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED
THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that 1 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. Uc. N Class q
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I 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).
Lender's Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that 1 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).):
Ai 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 appy 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. If, 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 contraclors Ucense Law does not appy to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ 1 am ex t Business and Professions Code for this reason:
Signature: Date: _ _ -4-6-06
Owner ID v rifled by driver's license. ❑ Yes ❑ No Driver's Ucanse No. ? - Expires: 4. 2 F - I
Verification of Ownership by (type of document, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 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, felsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Title B, 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 WIII the applicant or present or future building occupant need to file and certiy 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 o1 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 meterials7 � Yes ❑ No
(Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costs Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greeter 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)?
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, cedilicatlon and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4.._...II an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully compiled with? ❑ Yes..........._❑_No................._............................._._.. _
...................................__...............__..................................._._...__....__........__._......................._................................................................................................................................................................................................_.._......
5 Does or will the applicant or present or future buloing occupant require for the work which is the subject of this a pliratlon a permit for such construction or modificadon
from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes LJ No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
e WIII any pen of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑ Na
(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 Duality 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
......................................................... ....... ............................................... ___._.._..._._........................._......................._................................................................................................____._.__..............__..__.._...__...__
B (II yes', attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of penury 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. 1 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 tor' s cli rposea. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
-�) - 6-06
Signature Of Legal Owners) Date
And/Or Authorized Applicant Date
CODE t. INSPECTION TYPE 263 NITA CODE I INSPECTION TYPE 2A¢ 19MLS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 206 Final Plumbing
200 Final Re-Roof 210 Final Electrical
201 Final Block/Retaining Well 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.011ALDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626
Job Address:
356 16TH PL
Status:
ISSUED
Suite:
Applied:
05/302006
Vicinity:
THROUGH OUT HOUSE
Issued:
05/302006
Primary Occ:
R3
Type of Construction: V -N
Parcel Number:
42519219
Zoning:
Applicant:
KAYLOR,GLENN
Address:
P O BOX 11723
-Phone: 949-212-5721 ISSUED Y:
COSTA MESA, CA
Zip: 92627.
Owner:
KAYLOR,GLENN
Address
P O BOX 11723
- -
Phone: 949-212-5721
COSTA MESA, CA
- Zip: 92627
Contractor:
OWNER -BUILDER -
Address:
Phone:
Zip:'
License: 000000
Arch : -
Eng:
Address: _
-
- Address:
- - Phone:
-- Phone:
Zip:
..License:
License:
SCOPE OF PERMIT
CHANGE OUT 10 WINDOWS (THROUGH OUT DUPLEX) LIKE FOR LIKE, AND CONVERT 2 WINDOWS INTO 1 SLIDING GLASS DOOR AND 1
. FRENCH DOOR, NO CHANGE IN HEADER FOR DUPLEX. WINDOWS SHALL MEET 1997 UBC EGRESS REOIREMENTS.
FEE SUMMARY
Plan Check:
$0.00
Calc Valuation:
$4,000.00
Permit:
$97.25
Claim Valuation:
$4,000.00
SMIP Res:
$0.50
SMIP Com: ,
$0.00
Other:
$0.00
Inspection:
$0.00
Total:
$97.75
:f
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, 0-0
PARKING
Existing:' -� 0 Required:
;- O< . Proposed: 0
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: 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
2o4e4e (6=)
DECLARATIONS
WORKERS' COMPENSATION DECLARATION: '
I hereby affirm under penalty of perjury one of the following declarations:
f
❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 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:
Carder: Policy Number:
(This section need not be completed if 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 C litornia, and agree that it I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
#`—comply with these o 1
Applicant Signature:.
CWARMNCv'�FAAURE TO �6ECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUSIECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED WR 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. # Class #
Contractors Signature: Date:
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: Lenders 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
Cade: 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).):
^--1, 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.
� _704'4, 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 contraclods)
license pursuant to the Contractors License Laws.).
❑ 1 am ex T�i t d Business and Professions Code for this reason:
Signature: / / Dale:- - ' l]
�
Expires:,
Verification of Ownership by (type of document, i.e. - property tax bill or deed):"`--' e
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, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Title 8, California Administrative Code).
❑ As owner -builder, 1 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 Safely 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 torte 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 It an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? []Yes ❑ No
........ .................. ... ... ............................................................................ ................... ... ....... .......................... ... .................................................................................. I ................................ ............
5 Does or will the applicant or present or future building occupant require for the work which is the subject this a�ppplication a permit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? u Yes IJ No
(Section 65850.2 of the California Goverment Code requires that the requested information be furnished on applications for non-residential . building permits).
.................
..................................................................................................................................................................................................................................................... _.... ...................... _ ................................
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? [I 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? ❑Ves ❑ No
.................... ...........................-.............. ...................................... ............................. ........................ ....................................... - ....................................................................... .................................... ... .......................
8 (if 'yes", attach certificate of compliance from the appropriate air 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 3Rcomply 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-describ r e purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Signature Of,Legal O,wner(s) Data' A
's»
Date
CODE N, INSPECTION TYPE DATE INTMALS CODE IIS INSPECTION TYPE INT1TfAU$
1616 FixxedSystemlFinal Fire Prevention 1 206 Final Mechanicals
1266 Pool Spa Fidel - - 208 Final Electrical
`iv "� �•
200 Final Re -Roof �\�\d�1' � � 210 Final Electrical
201 Final Bloc` Retfl ,ng.Wall 1 212 I Final Fire Prevention /
202 Final Factory Fire Place ' 220 Final Planning Approval >;
203 Final Sign \\\ ` �% 222 Final Site _
/ Y
204 Final Demolition --�' 250 Final BuildingtOccupancy
COSTA MESA BUILDING -SAFETY DEPARTMENT
P.O. BOX 317 COSTA MESA. CALIFORNIA
fOR APPL/CANT TO f/ll /N COMPLETELY
TYPE OR PRINT
ADDRESS ti
COSTA MESA. CALIFORNIA
S=EE RECEIVE®
FINANCE DEPT.
CITY OF COSTA MESA
APPLICATION FOR PERMIT
BUILDING
W offla wir oNCY
1 ( /
•..�
RECEIPT NO. PERMIT NO.
OWNER /
MAIL /
9/��E�ECEIVED I DATE ISSUED
RECEI�-
"DRESS
/
TEL.
BUILDING
CITY NO.
ADDRESS
ARS JCT u.
R
OINTER NO.
COSTA MESA. CALIFORNIA
ADDRESS
FIRE
ZONE TYPE GROUP
I STATE
CONTRACT LIC. NO.
BYDATE
ADDRESS / �✓ O
ZONING
LEGAL LOT M
I I �RACT /
ZONE NO. OF USE OF NEW
�. I
I
DESCRIPTION. NO. BBLOC/K
PLANS BUILDING
6 " 1
A.P. NO. / / (�
By DAT DATE
SIZE "� "7 (J I NO. OF BLDGS. /
YARDS EVES
OF LOT / d rvow ory LOT (
REQUIRED ALLOWED
USE OF
(CENTER LINE ST.1 6
EXISTING BLDG.
FRONT IN.
SETBACK LINE FROM
CENTER OF STREET REAR YARD
R. SIDE FT. IN.
SIDE YARD ILEFT (RIGHT
L. SIDE FT. IN.
DESCRIPTION OF WORK
REAR IN.
NEN II ALTERATION I ADDITION
'DEMOLISH
/(11(11
REPAIR II MOVING II✓ II
BUILDING NO.OF
SIZE ROOMS STORIES
EXTERIOR WALL (ROOF
COVERING COVERING
USE OF BUILDING AND WORK TO BE PERFORMED
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM.
THE AMOUNT SHOWN UNDER VALUATION IS FOR THE
PLY WITH ALL CITY ORDINANCES AND STATE LAW REGULATING
PURPOSE OF ESTABLISHING A PERMIT FEE ONLY.
BUILDING CON c or. ,
�
VALUATION �f
)
SIGNATURE O /
PERMIT FEE $
eIL-v PLAN CHECK $
!(/
AUTFIORIZF, A ENT
TOTAL FEE $