HomeMy WebLinkAbout376 RAMONA WAY - Building Permits • CITY‘3F COSTA MESA
BUILDING DIVISION
's
F ,.,,,- I DEVELOPMENT SERVICES DEPARTMENT P MIT NUMBER
PERMIT B07-00300
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.dtS.IISL LING PERNtti 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 376 RAMONA WY Status: ISSUED
Suite: Applied: 03/13/2007
Vicinity: ROOF Issued: 03/13/2007
Primary Occ: R-3 Dwellings/Cong Res<10 Type of Construction: V-N
Parcel Number: 42531144 Zoning:
•
Applicant: HAMMARSTROM, H. I /
Address: 18903 SAN CARLOS ST A1�
Phone: 714-655-2231
FOUNTAIN VALLEY,CA Zip: 92708 ISSUED BY:
Owner: CROOK, KIMBERLY B
•
Address 376 RAMONA WAY
Phone:
COSTA MESA,CA Zip: 92627-3766
Contractor: ABSOLUT ROOFING INC
Address: 18903 SAN CARLOS ST
Phone: 714-655-2231
FOUNTAIN VALLEY,CA -
Zip: 92708 License: 761118
Arch : Eng:
Address: Address:
' Phone: • Phone:
Zip: License: License:
SCOPE OF PERMIT
TEAR OFF EXISTING ROOF.INSTALL 1/2"PLYWOOD,5:12 PITCH,30#FELT PAPER,50 YEAR CLASS A PRESIDENTIAL COMPOSITION BY
CERTANTEED.3,500 S.F.
FEE SUMMARY
Plan Check: $0.00 Calc Valuation: 59,850.00
Permit: $181.25 Claim Valuation: 59,850.00
SMIP Res: $0.00
SMIP Corn: $0.00
Other: $0.00
Inspection: $0.00
Total: $181.25
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: 0 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
244646(W00)
DECLARATIONS
WORKERS'COMPENSATION DECLARATION: •
I hereby affirm under penalty of perjury one of the following declarations: •
❑ I have and will maintain a Certificate of consent to sell-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.
❑ I 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.
L -My workers'compensation Insurance carrier and policy number are:
,Carrier:- - 5114/1- 47.140 Policy Number: iS 8/SSQ
(This section need not be completed If the permit is valued at one hundred dollars($100)or less.)
❑ I certify that in the performance the
yv�)/,,,/4kk for which is permit is issued,I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of Cal ndF, that if I out ome subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these p
-Applicant Signature: �l// Date' 3 . 13-07
l WARNING:FAILURE TO SE',;ONE WORKE S'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($100,000),IN ADDMON TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that Lam lic;•sed under,provisionsof 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.# Q / Class# C SI
Contractors Signature: 7/, M #7V 7-Date: 3'/3'07
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 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 penally 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.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 end 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 contractor(s)
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 driver's license. 0 Yes 0 No Driver's 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,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,Califomia Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit 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 certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑Yes 0 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? 0 Yes 0 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 Dusinesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health end Safety Code been fully complied with? 0 Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application apernit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? D Yes LJ No
(Section 65850.2 of the California Govemment Code requires that the requested information be fumished on applications for non-residential building permits).
6 WIII any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 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? 0 Yes 0 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 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.
•
Signature —•al Owner(s)
- Date
( An Or h thorized Applicant (—Date
COPE r INSPECTION TYPE PdIE - INRRALS CODEt INSPECTIONTYPE PAIL LNTMLS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final ® 20 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
`u "I.lI. 111-1HV V1Yfl'Y 1lVLIJA'1 Lis"IL •- —rI/
JOB ADDRESS 376 Ramona Way BUILDING PERMIT NO. 39567
GENERAL CONTRACTOR Owner H1dr. DESCRIPTION ofWORKAdd Storage Garage
AP No. 117-264-84 LOT TRACT FIRE ZONE VALUE $ 1,200.00
INSPECTIONS Signature Dote TYPE V GROUP S ZONE RI
SOIL PERMITS ISSUED
GAS SUBCONTRACTOR — -
Date I Number I Signature
WATER Plumbing
ROUGH PLUMBING
PROP. SWR. LINE 0 HOUSE CON. 0
SPRINKLING SYSTEM
MISCELLANEOUS
ROUGH HEATING AND AIR CONDITIONING •
TEMPORARY SERVICE OR POLE
UNDERGROUND E POWER fl
ROUGH WIRING Heating and Vent.
TRENCHES 2 FORMS l� STEEL REINF. I Y e'4! ,, n „
FLOOR SYSTEM
BOND BEAM rl STEEL REINFORCE n
SHEATHING �5 5 y7-7<-
FRAME AND FLASHING - .f q, 3'17-94-
LATHING - IN 7OUT I^4./ 7
PLASTER, BROWN COAT
STRUCTURAL, FINAL Electric
HEATING, VENT., REFRIG. AND A.C., FINAL .
PLUMBING, FINAL AND GAS TEST n
ELECTRIC, FINAL .�
BUILDING, FINAL _- ,,6 1-4 .75/
, _
39567 ==P =--.
75oo ora.: ****1 8.5C
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626
For Applicant to Fill in Completely APPLICATION FOR BUILDING PERMIT
REC IVE BY DATE ECE�.IYYcED DATE ISSUED
BUILDING �. ✓ // */
ADDRESS 376 Ramona Way r/! Ot�4/'
P 73.
OWNER — Robert BEAUCHAMP A.P.NO, 117-264-84 6
MAIL BUILDING
ADDRESS 376 Ramona Way ADDRESS76 RRAMON��/�1p?Y�
Lu
0 CITY Costa MEsa, California Nui O. 642-3480 TRACT L.
/ft!(��%3 LOT �7� BLOCK
1— Z
Z < CONSTRUCTION NEW ADO ALTER REPAIR MOVING DENIM ISH
O N LENDER N/A
am X
J D BRANCH '
JLn OWNER ROBERT D. BEAUCHAMP
CO J ADDRESS VALUE /�,�
_i<
m ARCHITECT TEL. USE Storage - Garage $ 2s/V
OR ENGINEER N/A NO.
(// FIRE
w m ADDRESS ZONE 3 YPE V GROUP J
a Ly APPROVED
JDCONTRACTOR Owner-builder BY DATE,—LOS
m Z VVP���
J Er ADDRESS at .1Ot
W W TEL. ZONE NO.OF USE OF NEWC7A',.A _
z� CITY Costa Mesa NO. 642-3480 R1 PLANS BUILDING 57og,%$. ,4
ab
—O STATE CITY YARDS APPROVED YARDS APPROVED
tu
N m LIC.NO. LIC.NO. MAIN BUILDING ACCESSORY BUILDING
7 SIZE 'NO.OF BLDGS (FROM C/L STREET) 'I ��Q�
OF LOT 6215" X 140' NOW ON LOT 2 ,�•'{
FRONT FT. .z
USE OF J�s
EXISTING BLDG. Garage — detached R.SIIIF FT. n2f T.
I— SIZE OFNO.OF
Q NEW BLDG. 20' x 12' ROOMS 1 STORIES 1 1 SIDE FT. /Q FT.
U EXTERIOR WALL ROOF asphalt
_ COVERING StUCCO COVERING Shing a REAR FT. a' 3' FT. -
J USE OF BUILDING AND WORK TO BE PERFORMED
DISTANCE BET. BET.MAIN&
CL
CARACF - STORAGE ADDITION MAIN BLDGS. ACCESS.BUMS.
Q VAR.* DATE
O C.U.P.sfs APPROVED
I— APPROVag ,/) iti—
O Sre)
r,
D I hereby acknowledge foon I have reathis arae to application and state �y-v(/ '
AX
� that the above Information is correct and agree to comply with ////
all laws regulating building construction, end I shall not employ
F any person in violation of the workman's compensation laws of
CO the State of California. //� CO
I hereby certify that I am properly licensed as a contractor under L:1'{ SO. FT. o
the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR •
Chapter 9, and that such licenses are in full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY:
am exempt from the provisions of the State of California Business yU
and Professions Code, Division 3, hepta fC
VALUATION /, n
Si-- PERMIT FEE $
Signature of Qry� ��/ ,1 /ld (��l m
Permittee X 4`e.d: % , GGL� g�� 2U� PLAN CHECK $ (Q —' E
OBERT D. BEAUCHAMP // e-r
Authorized Agent / ` / . -
TOTAL FEE s
OWNER BEAUCHAI4P RO• RT D. DATE 11-16-60
JOB ADDRESS 376 Ramona Way BUILDING PERMIT NO.132;7
GENERAL CONTRACTOR Male r-Bldr. VALUE $177.00
AP. No. 117-263-21 LOT TRACT _ FIRE ZONE DESCRIPTION OF WORK Enclose Porch
INSPECTIONS DATE I GROUP I TYPE % V ZONE Rh
Underground Soil U.G. Water PERMITS ISSUED
Underground Gas --- SUBCONTRACTOR 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 Forms Steel
Floor System
Steel Reinforce Chimney Re-Rod
Bond Beam
Sheathing
Frame and Flashing F-,rt1 //AS-,4,
Lathing, In Out ?M //-A.K -6o
Plaster, brown coat TSN /2 -
Plumbing Fixtures, Final
Electric Fixtures, Final
Building, Final '� --(•il 4-1-1't- -s 1
OCCUPANCY
Form 2W-5M-11.59 S-B P 13287
nC114:37 FEE RECEIVED
COSTA MESA BUILDING-SAFETY DEPARTMENT vNANCE1DEPT.
61960
P. 0. BOX 917 COSTA MESA. CALIFORNIA
CITY OF COSTA MESA Applicant to Fill In Completely APPLICATIONFOR PERMIT
TYPE OR PRINT
A.� ? BUILDING
BUILADDRESS 37G 1�H' {i7evrr w t�(
COSTA MESA. CALIFO7NIA For Office Use Only
A
t '` �/_ ��� I RECEIPT NO. 11t3ft TMD
OWNER v h Alll 1r/'J11 �Q 9144
ADDRESS 371a ' I?&P1o1n/Ia L-'Lfrif aec v : I //,7/7, I BoAn B/B^ D
CITY UOS Ip /gym/ZS;T
AL. 4tq ADD EISS !Y JC7 S/CA A/6L -6/V/
ARCHITECT TEL. COSTA MESA. CALIFORNIA /
OR ENGINEER NO.
FIRE
ADDRESS 5601r= ZONE TYPE GROUP A /
CONTRACTOR (HOME CIA/Mak SMILGSE7.
�!
R APPROVED I I DATE// 4 4P
ADDRESS 5/7/1/k--- ONING
//+ M> SON NO.OF USE OP NE }� I
CITY ( tom?s �� / //} �� I PLANS %/I BUILDING ��t JI i /
STATE TEL. r / 3 / N vvll//11
LIC.NO. `�`' NO. DESCRIPTION //F )/2,... /(0_ T 6-+
SIZE / J NO. OF SLOGS.
OF LOT G 3.} ix NOW ON LOT 2 A.P.NO. fr7 - 2 C - /
USE OF YARDS EVES
EXISTING BLDG. HO Mil- 4 PR 145 a APPROVED ALLOWED
SETBACK LINE FROM % �7( / (CENTER LINE ST.1
CENTER OP STREET j'7 REAR YARD75 5 FRONT <7 ... FT. IN.
% I / J
SIDE YARD I LEFT 13 RIGHT 2O R.SIDE C-41-0-2-0-..-.! (-✓G-."qt,
DESCRIPTION OF WORK L.SIDE CFR c.,..-t•10-41- j'—IiS" -..
NEW I II ALTERATION IS II ADDITION I X REAR /1 D4.4.,
/�CRT e)- -.t PCTN 2�
REPAIR I II MOVING I II DEMOLISH I APPROVED `, /I�U I I , TE 2- , r.. /D
BUILDIN / 4610. OF v CI'w 151_-
SIZE
L_
SIZE L✓A ti ROOMS ,. STORIES
EXTERIOR WALLC ,�•c , I COVERING O ���///
ROOF
COVERING ✓ �) '/4
USE OF BUILDING AND WORK TO BE PERFORM D' //..�� /- j� /� /
/r/1 Pier e�� Of 74974- oT gorc K,
FKvn/f ENig/ luny
I HEREBY ACKNOWLSDOE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION iS FOR THE
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM- PURPOSE OP ESTABLISHING A PERMIT PEE ONLY.
PLY WITH ALL CITY ORDINANCES AND STATE LAWS ULATING
BUILDING CONS CTI//yN. (FiD VALUATION . �)
SIGNATURE OF /1/1 F� �J� PERMIT FEE $-7C/
PERMIT-IMF t Iv ��/JJ}///��) N
8/77________..-- PLAN CHECK $ •
I
AUTHORIZED AGENT ^J >
ITOTAL FEE $(JC y
OWNER BEAUCHAMP, ROBERT D. DATE JAN 8,1964 ,
JOB ADDRESS 376 Ramona Way BUILDING PERMIT NO. 21297
GENERAL CONTRACTOR Owner-Builder VALUE $ 7,500.00 2Ba:,Fa
AP No. 117-264-84 LOT TRACT FIRE ZONE 3 DESCRIPTION OF WORK Add to Res. .2St
INSPECTIONS SignatureDATE GROUP TYPE ZONE g•
i Soil 1 /y-Ly PERMITS ISSUED
Gas SUBCONTRACTOR DATE NUMBER
Water
Rough Corn. Refrig. 0 Air Cond. 0
Rough Heating p
tough Plumbing Ve. , .s/23b,- e-,, ,,,i-,.J z- .P 7651 5'..2 /a S`
Miscellaneous
Prop. Swr. Line 0 House Con. 0 St. Swr. 0
Sprinkling System
Construction Pole
Underground ❑ Power 0
Rou_h Wiring ij-61-., 41./3-Cy .�c -✓ i=J�' ‘,L a i 73G •
Trenches' Forms El Steel Reinf. 0 C/� / qC
Floor System
Bond Beam 0 Steel Reinforce 0
Sheathing r �e.�
Frame and Flashin_ /"
e-' 6;476��
Lathing — In[n Out x[11 a.7.2-)2._E- 2; 474
Plaster, brown coatnk 9.- "
Refrig. 0 Air Con. 0 Final
Heating, Final
Plumbing Fixtures, Final .'J/ y ,/,6y'
Final Gas Test y�,�
Electric Fixtures, Final P�_J{� Jo 6"/
Building, Final 4' S 2 4
.
OCCUPANCY
Form B1.74—SM—,63—S-B P
7itln
- 21297 FEE RECEIVED .�..
COSTA MESA BUILDING-SAFETY DEPARTMENT �AN 8 1964
P.O.BOX 317 COSTA MESA,CALIFORNIA • FINANCE DEPT.
9Ij QF COSTA MESA
For Applicant to Fill In Completely A L C TION FOR PERMIT
TYPE OR PRINT BUILDING
BUILDI 9 �' I � y For Office Use Only
3�� /�H/L/0/G R 1//
RECEIPT NO. "i N'1 7
COSTA MESA. CALIFOR A )
�.. 6 - R8C81V BY pATeq 711/Tyl. AT yp(1 p.
OWNER cO of.j:12 f D Ill?/4 Lt c /� j). / Off/ F/r11y Orin,
p L/ BUILDING
MAILADDRESS S4 rt? E ADDRESS ('//
VIRE
��// frill L
TEL ZONE -E / GROUP
CITY (-'OS/ NO. •I TY4 1 r/ Q,
APARCHITECT lam' (/ �L. L I ?coo
EYPROV ED ZONING DATE
OR ENGINEER 117
"/
Ob P.-R# 4 �T
ADDRESS SA pia_ •elx/r.�
20N/ NO.OF USE OFNEW
'M ' PLANS . BUILDING
CONTRACTOR (N.,A/M fZ '1 J� ` 1
LEGAL 7_ �3 / I
ADDRESS S4n.(t _re D[[CRIRIO �7 O�-A�/toll
� /,yr /P) rrJX��� f'
CITY S9/L,K.
A.P.NO. ,/ — ato /
NOTE: NO EAVE OVERHANG SHALL BE LESS THAN
STATE ..--_ TEL. — SO'TO SIDE 3 REAR P.L.
LIC.NO. NO.
/ EAVES
I OFLOT A 7'p 7��` I 36l U yi NOW
ALLOWED (U.B.C.REQUIREMENT)
}� YARDS APPROVED YARDS APPROVED
ISTONG BLDG. VWIY L1_ J MAIN BUILDING ACCESSORY BUILDING
EX
f FROM ClL STRF'Efi ''
SETBACK LINE FROM .{ 3 / FRONT/•fj(...b=r Pf Zi ^/
Y� PT.
CENTER OF STREET J I REAR YARD �f
F/ / �� •r 9/ R.SIDE /n FT. - 1�+`Y�/� • FT.
SIDE YARD LEFT / 9 I RIGHT l 7 [ � ��77 �(a//
DESCRIPTION OF WORK L.SIDE C--44.dG �d .-Q-29. FT.
NEW _ ALTERATION ADDITION X REAR 3 O FT.3 FT.
DISTANCE BET. BET.MAIN&
MAIN BLDGS. ACCESS.BLDGS.
REPAIR _MOVING DF,MOLISH
VAR.# DATE
BUILDING �j NO.OF
SIZE / f�0 ROOMS � STORIES i C.U.P.# APPROVED /
EXTERIOR WALL ROOF A^ APP'• H
COVERING S MCCO COVERING `?H P -Y I. • 'J` 1 a DATE •- r-(0
USE OF BUILDING AND WORK TO BE PERFORM-• /
/Y/V/n)//VR74 3/ /"'fury it/Y -fOA'�'/ 7 /�
(�C// /Cath Pe`` fP740 f e 'try v I �" SQ.FT. T
I HEADY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION' THE AMOUNT SHOWN UNDER VALUATION IS FOR THE
AND STATE THAT THE ABOVE IS CORRECT
AND/A{GGRRpEE TO COM PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. 0
BUILDIPLY ING CONSTRU ORDINANCES AND STATE LAWS [OULATING VALUATION �j m •
�/�rDJ//�/ PERMIT FEE $ 2 / j
SIGNATURE OF /�"✓• �jl ODS m
PERMITTER '(/ , //'], ��77 L��J
Uf - / PLAN CHECK $ /`�/✓ `� o
r
2
AUTHORIZED AGENT TOTAL FEE $ �Or 6J yte)